Coding and Billing for Internists’ Services Challenges and Opportunities

1. Coding and Billing for Internists’ ServicesChallenges and Opportunities June 2010

2. Foundation on which Billing and Coding is Based • AMA maintains CPT book of codes that describe physician services • CMS supplements the CPT book as needed • RBRVS, managed by CMS, determines payment for each physician service • Each service has a relative value for each of three main components—work, practice expense, and professional liability insurance, with each being adjusted to reflect geographic input price differences • Medicare multiplies total, adjusted relative value for each service by a dollar multiplier, or conversion factor • Medicaid, other government, and private payers generally use RBRVS as basis for payments

3. Medicare Payment Uncertainty • Medicare annual payment updates lag behind medical inflation • Flawed sustainable growth rate formula regularly calls for unsustainable cuts in Medicare physician payments • Congress typically acts to replace an impending cut with a freeze or small increase around time it is to take effect • Congress almost certainly will act to avoid large cut but is avoiding a complete long-term fix because it’s costly • ACP participating in this messy process to represent the interest of its members

4. Focus on What You Control • General coding and billing guidance • Do what is medically necessary • Document what you did according to guidelines • Use up-to-date CPT and diagnosis codes • Investigate payment denials • Conduct periodic self audits • Engage in continual coding and billing education • Understanding coding and billing rules is vital to health of practice • Coding and Billing Challenges and Opportunities

5. Challenge: “Welcome to Medicare” Exam Benefit • Changes in 2009 resulting from 2008 law implementation: • Patients now eligible 12 months after enrollment, instead of 6 months • No longer required to perform EKG, but must advise/refer as needed • Now required to conduct BMI and discuss advance directive • Use new HCPCS G0402, instead of old G0344 • Can bill medically necessary E/M on same date as appropriate—use modifier -25 • ACP has contended pay too low; CMS increased pay for service for 2010 to $154, up from $92 • CMS working to establish details of an annual wellness visit/preventive care plan benefit for 2011 as required by March 2010 federal health reform law

6. Challenge: Billing for Consultations • Requirements for a billing a CPT consultation service code: • Furnished at the request of another physician seeking opinion or advice • Must make a treatment option(s) decision/recommendation • Must provide opinion or advice in a written report back to the requesting physician • Consulting physician can initiate treatment, e.g., diagnostic or therapeutic tests or procedures, during consultation visit • On-going care furnished by the consultant after initially providing opinion or advice is billed using office, subsequent hospital, nursing facility visit codes

7. Dramatic Medicare Consult Policy Change • CMS no longer recognizes CPT consult codes for Medicare payment purposes beginning in 2010 • CMS rationale for change: • Agency long-expressed concern that physicians did not bill consults correctly • Reviews determined that Medicare overpaid as many consults billed were not supported by documentation • Agency believes consult service work is “clinically similar” to office, hospital, NF visits

8. Dramatic Medicare Consult Policy Change • Consults to be billed using CPT codes for: • Office visits, 99201-99215 • Initial hospital care (admit). 99221-99223 • Initial NF care, 99304-99306 • Change was unexpected and has far-reaching implications • ACP position on Medicare consult payment policy is at http://www.acponline.org/running_practice/practice_management/payment_coding/medicare/changes2010/feeschedule.htm#advocacy

9. Documentation Implications of Consult Change • Documentation rules for “replacement” codes apply based on code used, thus: • No requirement that the requesting and consulting physician document request in medical record • Consultant not required to send a written report with opinion /advice back to requesting physician • No need for auditors to distinguish a request for a consult from a referral that constitutes a transfer of care • Admitting physician bills initial hospital care code with a “AI” modifier to distinguish service from consultant(s)

10. Payment Implications of Consult Change • To redistribute the money that Medicare paid for the no-longer-recognized CPT consult codes: • Payment for each office visit increased about 3% • Payment for initial hospital and initial NF care services increased about 1% • In general, payments for consult services will be lower as a result of use of CMS-required replacement codes

11. Payment Implications of Consult Change

12. Payment Implications of Consult Change

13. Payment Implications of Consult Change • No clear guidance on how to bill low-level hospital consults as no initial hospital code match for 99251-99252 • Consults furnished to established outpatients, 99211-99215, experience biggest payment hit • Consult for pre-op clearance on known beneficiary dictates billing established patient office visit • Physicians who do a significant number of consults will see overall revenue decline; those who do few see revenue rise • Confusion when a secondary payer is involved

14. Payment Implications of Consult Change • Can bill prolonged service code in addition to an office or hospital visit code (as appropriate and if documented) • Consult can be billed as critical care service if it meets the CPT definition of critical care • Coordination of care could suffer if consultants feel less compelled to send a written report to requesting physician • Most private payers initially decided to continue to pay the CPT consult codes but more are adopting the Medicare policy

15. Tips for Billing Private Payers Consults • Consultants can receive higher payments from private payers still recognizing CPT consult codes • Consult can be furnished by a physician in the same group as the requesting physician—consultant is expected to practice a different specialty but exceptions are made for same-specialty expertise • The service resulting from a surgeon’s request to clear a patient as being fit for surgery can be billed as a consultation for major procedures • Check if private payer follows the old Medicare rule that allows billing a consult for patient-initiated second opinions before major surgery or test

16. Challenge:Medicare Teaching Physician Regulations • Medicare pays teaching/attending physician for services furnished involving a resident when: • Services performed by teaching physician—duplicates resident service • Services performed by teaching physician jointly with resident • Services performed solely by resident under Primary Care Exemption • For first two scenarios, teaching physician must personally see the patient, perform the critical/key portion of the service, and participate in the management

17. Teaching Physician Regulations • Teaching physician must tether/link note to resident’s note • Billing is based on the combination of the teaching physician’s and resident’s documentation • Examples of acceptable documentation: • I saw and evaluated the patient. Discussed /w resident and agree w/resident’s findings and plan as documented in the resident’s note. • See resident’s note for details. I saw and evaluated the pt and agree with the resident’s findings and plan as written. • Examples demonstrate saw patient, performed key portion, and participated in management

18. Teaching Physician Regulations • Examples of unacceptable documentation: • “Agree with the above.” • “Rounded, reviewed, agree.” • “Discussed with resident. Agree.” • Signature alone • Other documentation tips: • There is no royal “we”; use “I” to demonstrate involvement • Can use template/macro, such as through EHR, but must sufficiently modify to reflect specific encounter/scenario

19. Suggested Teaching Physician Documentation I saw and evaluated the patient and reviewed (Resident’s Name) notes. I agree with the history, physician exam and medical decision making with the following additions/exceptions/observations : ____________________________________________________________________________________________________________________________________________________________________________________ Attending’s Signature Date

20. Teaching Physician Primary Care Exception • Teaching physicians can be paid for certain services furnished solely by a resident when they are provided in outpatient facilities for which resident time is counted toward the direct GME payment to the facility • Teaching physician can only be paid for resident low-level outpatient E/M visit services, 99201-99203 and 99211-99213 • Resident must have completed at least six months of training program • Teaching physician cannot supervise more than four residents and must be immediately available to assist

21. Challenge: Billing for “Incident-to” Services • Medicare allows physicians to bill for outpatient services performed by personnel that are “incidental” but integral and be paid as if the physician performed the service • Incident to rules enable physician to bill 99211 when service furnished by office staff • This minimal service can be performed by any clinical staff member, e.g., medical assistant, RN, PA • More complicated incident-to rules pertain to billing of 99212-99215 • Service must be performed by CMS designated clinical staff PA, NP, CNS

22. Billing for “Incident-to” Services • Conditions must be met to bill for higher-level PA, NP, CNS services • Physician must perform the initial visit and establish the care plan for patient/condition • Physician must provide direct supervision, defined as in the office suite but not necessarily in the same exam room, and be immediately available to assist • Medicare pays 100% of its normal physician fee schedule amount • PA, NP, CNS can provide services that fail to meet the incident-to rules • The practitioner furnishing the service must be listed on the claim/bill • Medicare pays the practice 85% of its normal fee schedule amount

23. Challenge: Billing Anticoagulation Management Services • Medicare payment policy makes it challenging to be adequately paid for managing patients receiving long-term, outpatient anticoagulant drug, i.e., warfarin therapy • ACP helped establish new CPT codes in 2007 to provide a more rationale way for physicians to bill and be paid for anticoagulation management services • A code to report an initial 90-day period that involves at least 8 INRs, CPT 99363 • A code to report each subsequent 90-day period that involves at least 3 INRs, CPT 99364 • Codes encompass physician review and interpretation of each INR, patient instructions, dosage adjustments, and ordering additional tests

24. Billing Anticoagulation Management Services • CMS refuses to pay for these new CPT codes, which would generally increase amount Medicare pays physician • The agency retained its policy that the practice can bill a 99211 when office personnel has a face-to-face encounter with the patient, higher level when physician has direct contact • ACP is concerned that some Medicare contractors may prohibit billing 99211 unless there is a change in drug regimen, treatment plan • This compounds the problem by making an inadequate billing policy more restrictive • Check with private insurers to see if they pay for CPT 99363 and 99364

25. Opportunity: E/M Counseling Exception • Have option to select an E/M level of service based on time when counseling and/or coordination of care accounts for more than 50% of physician face-to-face time with patient • Compare total physician time for encounter to CPT “typical time” • Not subject to 1995 or 1997 E/M documentation guidelines • Documentation should note amount of time counseling and what was discussed (must be medically necessary) • List counseling time as fraction of total, e.g. “ccc 15/25” in addition to describing pertinent issues discussed

26. Opportunity: Home Health Care Plan Certification/Re-certification • Bill HCPC G0180 for certification of the initial home health care plan • Medicare pays $58 • Bill HCPCS G0179 for re-certification of care plan • Use if patient has received home health services within past 60 days • Medicare pays $44 • Document thought-process in agreeing with plan and/or in changing to better meet patient’s needs • Keep copy of approved care plan in record or be able to access it if needed • CMS goal is incentive to physician to carefully review home health agency care plans to ensure appropriate utilization

27. Opportunity: Smoking Cessation Counseling • Medicare covers for: • Patients with disease caused or exacerbated by tobacco use; or • Patients taking medications complicated by tobacco use • Covers 2 attempts to quit per year • Each attempt can involve up to 4 counseling sessions • Bill CPT 99406 for 3-10 minutes of counseling • Pays $13 • Bill CPT 99407 for >10 minutes of counseling • Pays $25 • Append modifier -25 to office visit (or other service) done on same date

28. Opportunity: Screening Pelvic/Breast Exam • G0101 - cervical or vaginal cancer screening; pelvic and clinical breast examination • Medicare covers annually for women at high risk or of childbearing age with abnormal Pap in last three years, and every two years for all other female beneficiaries • Pays $35 • Can bill in addition to other same-visit/date services: • Obtaining a smear for screening Pap test Q0091—pays $40 • Acute/chronic “medically necessary” service, e.g., 99213 • Medicare non covered comprehensive preventive billed to patient, e.g., 99397

29. Opportunity: Use CPT Modifiers as Appropriate • Modifier -25 – significant, separately identifiable E/M service furnished by the same physician on the same date as procedure or other service • Can be used to bill an E/M service on the same date as a minor procedure, e.g., joint injection • Can be used to bill an E/M service on the same date as a number of Medicare-covered preventive services, e.g., Medicare-covered screening pelvic/breast exam, HCPCS G0101 • Can be used to bill an E/M service on the same date as another E/M service in limited circumstances, e.g., critical care service in addition to initial hospital if patient crashes

30. Opportunity:When a Patient is “New” Again • You can bill a “new patient” service when neither you or a physician of the same specialty in your group practice have furnished a face-to-face professional service within the past three years • Patient you provided a flex sig two years ago, not a new patient • Patient for whom you read an x-ray two years ago (without seeing the patient) is a new patient • Pay attention when providing office visits, new patient visits receive higher payment • 99204 – pays $151 • 99214 – pays $98

31. Opportunity: Non-covered Medicare Services That Can Be Billed to Patients • Telephone services • 99441 - 5-10 min. medical discussion • 99442 – 11-20 min. medical discussion • 99443 – 21 -30 min. medical discussion • Must be initiated by established patient call to physician • Cannot be billed if face-to-face service results within 24 hours or if related to face-to-face service provided within past 7 days • E-service • 99444 – on-line service to established patient • Physician’s personal, timely response to patient inquiry that involves permanent storage of documentation pertaining to exchange

32. Non-covered Medicare Services that Can be Billed to Patients • E-service (cont.) • Can only be reported once during same episode of care over 7 days • Not related to face-to-face E/M service within past 7 days • Preventive Medicine Services, e.g. 99397 – periodic comprehensive preventive medicine evaluation, established patient, 65 years and older • Medicare considers above services to be “non covered,” meaning that physician can bill patient his/her usual charge • Not necessary to have patient sign an ABN form but good idea to discuss situation with patients in advance of billing them

33. Opportunity:Medicare Bonus Payment – PQRI • Medicare pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI) • Report on how care furnished compares to evidence-based clinical guidelines for a variety of medical conditions, e.g. diabetes, heart disease • Earn a 2% bonus for 2010 for reporting on how care provided aligns with quality measures, selecting from a variety of reporting methods • ACP resources available at http://www.acponline.org/running_practice/practice_management/payment_coding/pqri.htm

34. Opportunity:Medicare Bonus Payment – E-Rx • Earn a 2% bonus for 2010 for reporting e-prescribing events using a qualified e-prescribing system • List code G8553 on claim form to indicate an e-prescribing event associated with eligible encounters, primarily office visits • Receive bonus if correctly report code a minimum of 25 times in 2010 • Other reporting options, e.g., through an EHR, are available • ACP resources available at http://www.acponline.org/running_practice/technology/eprescribing/medicare_program.htm

35. ACP Contacts for Questions/Comments • Regulatory and Insurer Affairs Department • Brett Baker - bbaker@acponline.org • Debra Lansey - dlansey@acponline.org • Tenita Richards - trichards@acponline.org • Center for Practice Improvement and Innovation • Margo Williams - mwilliams@acponline.org