MEDICARE: UNDERSTANDINGWHAT IS HAPPENING AND PREPARING FOR 2013

1. MEDICARE: UNDERSTANDINGWHAT IS HAPPENING AND PREPARING FOR 2013 Association of Northern California Oncologists January 2-4, 2013

2. WE WILL DISCUSS • Why This Seminar Is Necessary • Documentation and Chart Review • Why Review • Coding Principles &Misunderstandings • Review Principles • Medical Necessity Very Important • Complexity of Decision Making • Frequency of visits vs illness • EHR and Templates • Chief Complaint Issues, Active Problem Issues • Cloning and Decision Making • Managing Change • MAC Contract for J “E” • 2013 fee schedule, Changes • Recovery Auditors (Formerly RACs) • LCDs and NCDs • Other

3. REPORT ON SPECIAL STUDIES OF E & M • Data Studies Show Medical Review is Necessary • OIG Findings –Consistent increase in high E&M codes • BESS Data --- Nationwide & Local, 12 or more mos old • CERT Data --- Nationwide & Local, recent findings • Palmetto GBA Data Mining --- Local searches • Who Was Reviewed in Recent Study • Outliers by Service Type / Specialty Type • Outliers of the Outliers (2 St. Deviations or more) • What Was Requested • 5 Charts per Provider per Code, single chart per service • Purpose • General Education of Physicians / Offices • Denials Followed by Contact from POE • Specific Education for Denied Physicians E&M reviews will continue!

5. TECHNICAL DENIALS • Many Chart Denials are for Technical Reasons • Missing or illegible provider signature or use of a signature stamp • Missing or unsigned physician orders • Illegible documentation • Failure to provide documentation for all dates of service requested • If Technical Denials Prevented or Corrected--- Claim Paid First Attempt • Up to 50% denials for technical reasons • Office staff should prevent that from happening

6. MEDICARE MANUAL SAYS: • Medicare will reimburse for all services that are reasonable and necessary for the diagnosis and treatment of an illness or injury or to repair a damaged organ

7. WE (PALMETTO) SAY: • The only way Palmetto GBA can know if something is reasonable and necessary is to read the complete documentation submitted • Only the physician treating the patient knows what is reasonable and necessary for that patient being evaluated and treated.

8. PURPOSE OF DOCUMENTATION • Communicate with Health Care Personnel • Physicians, colleagues • Other health care workers& caregivers • Remind yourself what is going on • Communicate with Others • Quality review (PQRI, P4P) • Peer review (PRO, hospital, licensing board, credentialing groups) • Patient transparency • Protect against liability issues • Insurance review personnel (pre and post pay situations)

9. BEST FORMAT FOR DOCUMENTATION • There is no best single format • Can use any & all variants • History, Exam, Decision, Order • Subjective, Objective, Assessment, Plan • Pre-printed forms – if specific • Electronic records – if specific • Printed / written legible notes • Explain to the reviewer • Nature of patient problems • How / why patient treated • What is next and why (decisions) • Expected outcome if known

10. DOCUMENTATION POINTS • Templates/forms OK, but must be individualized for each visit • Patient name, date, time, and ID of who documented chart • Computerized notes okay if individualized, but medical necessity still rules on review • Require time when service time related-e.g. face to face time • If poorly legible, or not properly signed--we must reject the claim

11. CODING & DOCUMENTATION DISTINCTIONS • NEW PATIENT VS. ESTABLISHED PATIENT • DIFFERENT CODES AND PAYMENT FOR EACH • RACS KEEP LOOKING AT THIS DENIAL • EFFECTS SAME SPECIALTY GROUPS • PLACE OF SERVICE • INPATIENT OR OUTPATIENT (E.G. OFFICE) • HOSPITAL, ED, SNF, ECF, HOME, ASC, OTHER • “LEVEL” OF CARE • REGULAR (5 OUTPATIENT, 3 INPATIENT) • CRITICAL CARE, OBSERVATION, EXTRA TIME • SPECIAL SERVICES (EYE, MENTAL HEALTH) • CONSULTATION, –GONE FROM MEDICARE 2010

12. DEFINITION: NEW PATIENT • PATIENT WHO HAS NOT RECEIVED SERVICES FROM A PHYSICIAN OF SAME SPECIALTY WHO BELONGS TO SAME GROUP PRACTICE FOR 3 YEARS • PATIENTS SEEN BY COVERING OR ON-CALL DOCTOR CONSIDERED PATIENT OF USUAL DOCTOR WHO IS UNAVAILABLE • NO DISTINCTION MADE BETWEEN NEW AND ESTABLISHED PATIENT IN EMERGENCY DEPT. • A REFERRAL VISIT NOT NEW IF SEEN FACE TO FACE FOR ANY OLD OR NEW PROBLEM IN ANY PLACE OF SERVICE WITHIN 3 YEARS

13. Document...Document...Document COGNITIVE (EVALUATION & MANAGEMENT) SERVICES • INVOLVE ALL PHYSICIANS WHO EXAMINE AND EVALUATE PATIENTS • REQUIRE DOCUMENTATION TO SHOW LEVEL OF WORK & LEVEL OF CODING FOR REIMBURSEMENT • ACTIVITY BASED, TIME BASED, OR BOTH • ALL SURGERY / PROCEDURES HAVE SOME INHERANT E&M SERVICES INCLUDED • E&M DOC. GUIDELINES COMPLICATED • MEDICAL NECESSITY A KEY FACTOR IN DECIDING APPROPRIATE E&M LEVEL • NECESSARY TO INTEGRATE DOCUMENTED CODING WITH MEDICAL NECESSITY OF SERVICE

14. CHIEF COMPLAINT HISTORY EXAM DECISION MAKING COUNSELING COORDINATION OF CARE NATURE OF PRESENTING PROBLEM TIME COMPONENTS OF (E&M) SERVICES

15. CHIEF COMPLAINT • “A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that isthe reason for the encounter, usually stated in the patient's words.” …..from AMA CPT • The reason for the encounter often sets the stage for what is needed in the history, exam, and decision tree. • New problems MAY take more effort than old ones • Medicare does not pay for routine patient visits except for one NEW TO MEDICARE visit and one annualhealthy assessment visit --may need to infer CC in some EHRs

16. Should be 99212---infer the work not the “regular check up” 99213 billed-- denied

17. PRESENTING PROBLEM • A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows:

18. The presenting problem(s) often dictate the "reasonable and necessary" aspect of the visit PRESENTING PROBLEM (OR PROBLEMS) • Minimal:A problem that may not require the presence of the physician, but service provided under the physician's supervision. • Self-limited or minor: A problem that runs a definite &prescribed course, is transient & UNLIKELY to permanently alter health status OR has a good prognosis with management / compliance. • Low severity:A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. • Moderate severity:A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. • High severity:A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

19. ELEMENTS OF HISTORY • SOCIAL • HISTORY • An age appropriate • review ofpast & current activities with information about: • - Marital status and living arrangements • - Current employment • - Occupation history • - Use of drugs, alcohol, & tobacco • - Level of education • - Sexual history • - Other relevant social factors PAST HISTORY • A review of the patient's past illnesses, injuries, and treatments with significant information about: • Prior major illnesses and injuries • Prior operations • Prior hospitalizations • Current medications • Allergies (eg, drug, food) • Age appropriate immunization status • Age appropriate feeding/dietary status

20. REVIEW OF SYSTEMS • An inventory of body systems seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. For the purposes of the CPT codebook the following elements of a system review have been identified … • The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options. • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Heme - lymphatic • Allergy-immunology • Constitutional symptoms (fever, weight loss, etc.) • Eyes • Ears, nose, mouth, throat • Cardiovascular • Respiratory • Gastrointestinal

21. REVIEW OF SYSTEMS • In all documentation, you should see all positive findings and pertinentnegative findings • In regard to the present illness, we would expect: • Positive findings of system related to present illness • Pertinent negative findings to systems related to present illness • Pertinent findings or comment on changes in systems that are listed as co-morbidities or secondary problems • Unrelated systems can be “within normal limits, negative, normal or unremarkable if they are

22. PROBLEMFOCUSED EXPANDED PROBLEM FOCUSED DETAILED COMPREHENSIVE Limited exam of affected body area / organ sys. Limited exam affected body area & symptomaticrelated body areas Extended exam of affected body area and any other symptomatic or related body area. General multi-system … ..Or complete single system and symptomatic or related body areas EXAM DOCUMENTATION

23. EXAM DOCUMENTATION • For the purposes of these CPT definitions, the following body areas are recognized: • Head, including the face • Neck • Chest, including breasts and axilla • Abdomen • Genitalia, groin, buttocks • Back • Each extremity

24. 1. MULTISYSTEM 2. CARDIOVASCULAR 3. E.N.T. 4. OPHTHALMOLOGY 5. G.U. (Female) 6. G.U. (Male) 7. HEME / LYMPHATIC 8. MUSCULOSKETAL 9. NEUROLOGICAL 10 PSYCHIATRIC 11 RESPIRATORY 12 SKIN You are likely to see multisystem exams on most oncology patients 12 TYPES OF EXAMS Multispecialty and 11 single specialty exams ANY PHYSICIAN CAN BILL A MULTI-SYSTEM EXAM ANY PHYSICIAN CAN BILL A SINGLE SYSTEM EXAM

25. DECISION MAKING • Decision making refers to complexity of establishing a diagnosis and-or selecting management options as measured by: • Number of possible diagnoses and/or the number of management options that must be considered • Amount and / or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed • The risk of significant complications, morbidity, and-or mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options

26. COMPLEXITY OF DECISION MAKING Comorbidities / underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making. • Four types of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity. To qualify for a given type of decision making, two of the three elements in Table 1 must be met or exceeded. • Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making.

27. DOCUMENTATION OF DECISION MAKING • There are instances where no change in care is a complex and high level decision BUT • This should be documented for review • Many EHR do not allow space for this • May be shown in “rule outs”, “possible dx”, or elements of physician thoughts • Orders or plans may show decision making • Decision making relates to that visit only • Where decision making is used to create higher level of code, we expect some indication in record

28. SELECTING A CODE-CPT AVERAGE TIME • 99211: Typically, 5 minutes are spent performing or supervising these services. • 99212: Typically physicians spend 10 minutes face to face with the patient. • 99213: Typically physicians spend 15 minutes face to face with the patient. • 99214: Typically physicians spend 25 minutes face to face with the patient. • 99215: Typically physicians spend 40 minutes face to face with the patient. • Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

29. MEDICAL NECESSITY OF E&M VISITS--OFFICE • New Patient Visits: • No visits for 3 years by physician • Require all 3: History, PE, Decision making • Subsequent Patient Visits • Require any 2: Hx, PE, Decision • 99211: Brief visit, no MD (BP check, sutures out) • 99212: Single problem, easy to dx and resolve • 99213: Average 10-15 follow up several problem • 99214: Complex patient, mult problems • 99215: Require extensive visit with full workup- new serious problem or patient with major risk to organ system or life

30. E&M VISITS-HOSPITAL • Initial In-Patient Visits: • First visit in hospital – and Initial Referral Visit • Require all 3: Hx, PE, Decision Making • 99221, 99222, 99223 levels if meets criteria • Usually full H&P needed by Attending MD • Subsequent Patient Visits in Hospital • Require any 2: Hx, PE, Decision • 99231: Brief visit-better-discharge soon • 99232: Average day, IVs, Dx tests, active Rx • 99233: New or worsening problems- • Discharge day - discharge codes for attending physician- (99231 for others)

31. Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition 99291 – 1ST 30-74 MIN. 99292 – ADD. 30 MIN The following services are included in critical care Interpretation of cardiac output measurements Chest x-rays Pulse oximetry Blood gases Information data stored in computers (eg, ECGs, blood pressures, hematologic data) Gastric intubation Temporary transcutaneous pacing Ventilator management Vascular access procedures CRITICAL CARE CODES Just being in an ICU does not necessarily warrant critical care codes!!!

32. TOOLS YOU CAN USE FROM PALMETTO • E&M Score Sheet Tool • Modifier Lookup • Denial Codes • National and Local Coverage Policies • On-line Claims Management Tool • Local Fee Schedules • Medicare Forms • FAQs • More available on our website www.PalmettoGBA.com/J1b

33. WHY AUDITS AND REVIEWS ARE NECESSARY • Many physicians do not understand E&M coding rules – or don’t want to • Electronic Records tend to automatically up-code many visits • Strict counting of number of elements does not always justify code • Individual services must be reasonable and necessary for patient and date of service • Frequency of services must be reasonable and necessary for patient • Outside reviewers find high number coding errors • CERT -- OIG • RAC --ZBIC

34. PALEMTTO GBA DATA COLLECTED …37 pages of physician names …1065 docs had > 12 level 5 visits per year …Large variety of specialties involved …Northern California Only…if all three states taken together would be three times higher Specialties: GP, IM, Hem-Onc, Emer Med, Cardiology, Pain Man,

35. Radiology Srvs in California 71010 & 71020 … 5-8-2010 • Southern California: • 56% of the total amount denied due to NO DOCUMENTATION received • 27% of the total amount denied was due to NO PHYSICIAN ORDERS received • 8% of the total amount denied was charges deemed to be NOT MEDICALLY NECESSARY based on LCD for Radiologic Examination Chest • 8% of the total amount denied was for a combination of biller errors, illegible documentation, incorrect / incomplete date of service or patient identification on documentation received, and missing, invalid, illegible provider signature

36. Radiology Srvs in California 71010 & 71020 … 5-8-2010 • Northern California: • 72% of total amount denied due to NO DOCUMENTATION received for review • 9% of total amount denied for invalid, illegible or missing PROVIDER SIGNATURE • 9% of the total amount denied was charges deemed payable to ANOTHER PROVIDER billing same procedure, date of service & beneficiary • 10% of the total amount denied for a combination of illegible documentation, incorrect-incomplete date of service or patient ID on documentation received, no chest X-ray report included with documentation, and charges that were deemed to be not medically necessary based on LCD

37. EXAMPLE: SPECIALTY 11 (INTERNAL MEDICINE) • There were 5,459 claims reviewed, out of which 3,724 claims were denied. The total dollars denied resulted in a charge denial rate of 49% • The top denial reasons identified from the review are: • 46 percent – Missing or incomplete documentation for this date of service • 35 percent – Level of service billed not supported; Down-coded claim • 7 percent – Illegible documentation • 4 percent – Incorrect / incomplete / illegible patient identification or date of service Nearly 2/3 technical denials

38. No more, no more !! LOOKING AT MORE CLAIMS • Reasonable and Necessary trumps pages and pages of documentation if only done for sake of “scoring points” • Electronic health records try to increase billed codes • Electronic health records • Often inconsistent • Sometimes incoherent • Still in their infancy • Doctors don’t know how to use or update properly

39. Get me outta here LOOKING AT MORE CLAIMS • Electronic Records Must be kept up to date for any visit • Concurrent illness must be concurrent & significant • Decision Making • Helpful if explained / listed / or documented • Important to list changes in care or diagnoses • Lab review should be included if records asked for in a review • Excess verbiage on some EHR still does not give extra value

40. Review of symptoms negative---is this in past week or in past ever….and is it necessary Problem list never updated and frequently has duplicate or even opposite diagnoses

42. 73 Y/O female inpatient hosp or SNF ID note: afebrile but draining wound—brief history 99311 hosp or equivalent SNF code Review of lab and low level decision making Follow up visit 3 weeks later

45. THOUGHTS FROM AN ADDLED REVIEWER • A Chief Complaint should not be a “regular visit” • Documentation should include all positive and pertinent negative findings • ROS should not be negative, normal, or WNL regarding the chief complaint or other positive problems • Exam should include all positive and pertinent negative findings • Exam of principal problem or reason for visit should not be normal, WNL or negative • If patient comes for oncology follow up, expect exam of areas at risk and all related structures • Unrelated areas of body can be examined and stated as within normal limits. • Frequent visits should are not always high level visits

46. MORE THOUGHTS FROM AN ADDLED REVIEWER • Repeated full histories (if unchanged) should not be cloned for each visit • Documentation of most any visit should not be exactly the same –word for word-- as former visits • Complicated patients with multiple problems nearly always have something different related to one problem • Decision making is subjective • Some decisions come automatically to some docs and not to others • Try to explain your thoughts as to how you plan to test, diagnose or manage a patient • Chronic conditions that relate to your visit count • True morbidity and risk to patient also count toward decision making

47. WHAT IF ONE IMPORTANT ELEMENT NOT PERFORMED • No real history available • Patient comatose • Patient demented • Patient drugged • Get history from other source (addendum) • From family • From old or new chart • When patients wakes up • If patient on way to emergency surgery • Key elements (heart, lung, vital signs) • Rest of exam when patient available • Emergency decision making usually high level

48. RESPONDING TO MEDICAL REVIEW & RECORD REQUESTS • WHO CAN ASK FOR RECORDS / DOWNCODE OR DENY PAYMENT • MEDICARE A/B ADMIN. CONTRACTORS (MACs) • PROGRAM INTEGRITY (ZPIC) CONTRACTOR • CERT CONTRACTOR • RAC CONTRACTOR • QIO • BUNDLING AND MEDICAL UNLIKELY EDITS (MUE) • PRIVATE INSURANCE COMPANIES (FOR MEDICARE ADVANTAGE)

49. MAC REVIEWS: WHO GETS REVIEWED DATA OUTLIERS • UNUSUAL FREQUENCY OF VISITS • UNUSUAL LEVEL OR PLACE OF SERVICE FOR PATIENT • POOR DOCUMENTATION IN PROBE REVIEWS SENT TO CONTRACTOR • PATIENT COMPLAINTS • REPEAT FALLOUTS & WARNINGS • POSSIBILITY OF FRAUD

50. PREPARE FOR REVIEWS:DO 1.GET PERSONALLY INVOLVED 2. COPY ALL OFFICE, FACILITY OR OTHER RECORDS REQUESTED: --PROGRESS / THERAPY NOTES (CURRENT AND EARLIER IF HELPFUL TO EXPLAIN) --NURSING NOTES, CLINICAL OBSERVATIONS, AND ANY CONSULT NOTES IF HELPFUL --LAB & DIAGNOSTIC TESTS IF RELATED TO SERVICE --ANY CHANGE IN DX, MEDS, OR THE CURRENT CONDITION 3. WHEN IN DOUBT SEND MORE RATHER THAN LESS TO SUPPORT MEDICAL NECESSITY OF SERVICE