Coding and Compliance

1. Coding and Compliance Community Based Providers 2005

2. Disclosures for CME credit There is no commercial support for this training presentation. There are no faculty disclosures to announce. No off-label use of drugs or devices are incorporated into this presentation.

3. Course Objectives Scope of the UNC School of Medicine (SOM) Compliance program CMS' interest in regulating teaching physicians Documentation of level and category of Evaluation and Management (E&M) services Accurate code assignment for equitable reimbursement Teaching physician (TP) documentation Differences in rules by specialty Resources available for questions

4. UNC SOM Compliance Office Mandate The purpose of the Compliance Office is to assist UNC P&A physicians and other practitioners with complying with governmental regulations to medical record documentation and coding for billed services. The principal activities include: Developing & maintaining the practice-wide compliance plan; assuring adherence to those plans Conducting faculty, resident and staff educational sessions on teaching physician regulations, documentation and coding of evaluation and management services and documentation of surgical and diagnostic procedures

5. UNC SOM Compliance Office Mandate developing and maintaining electronic databases of faculty, resident and staff participation in mandatory compliance-related training sessions conducting division-level, pre-bill medical record reviews of outpatient evaluation and management services, presenting results to division and department leadership and assisting with corrective action plans

6. UNC SOM Compliance Office Mandate monitoring trends over time through computer-based reporting responding to audit requests from external agencies such as the North Carolina Medicare carrier investigating and resolving incidents which may be breaches in the School's compliance plan  

7. UNC SOM Compliance Office Mandate researching compliance-related issues with Medicare, Medicaid and other governmental and non-governmental third party payers supporting residents in their key role of working together with the teaching physicians to assure that all patients receive the same high quality care and that that the documentation for Medicare patients reflects TP participation in the patient’s care.

8. CMS' Interest in What We Do Residents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents salary based on the proportionate share of Medicare at the teaching hospital. Teaching physicians are paid by Part B Medicare on a fee-for-service basis.

9. CMS' Interest in What We Do The government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service, the TP cannot bill. Beginning in December, 1995 the University of Pennsylvania, Thomas Jefferson, Pittsburgh, UT San Antonio, South Carolina, Virginia, the U Cal System, Chicago and seven or eight other schools of medicine have paid fines and penalties ranging from $2M to $30M. A whistleblower-initiated investigation at the University of Washington (2001 – 2002) resulted in a felony conviction for one of their department chairs.

10. CMS' Interest in What We Do Two problems caused the refunds and penalties: The TP billed and he/she may have been present and participated in the care, but TP presence was not documented. The documentation did not support the level of evaluation and management (E&M) services billed. The billed level of service may have been provided, but it was not documented.

11. Current Government Activities The OIG proudly trumpets $1.6 B in recoveries and fines in FY 2002 Highlights of FY 2004 OIG work plan for physicians Use of modifier 25 without documentation of medical necessity for an evaluation and management service on the same day as a procedure. Consultation codes inappropriately used, lacking proper documentation Disproportionately high volumes of high-level E&M services CMS Comprehensive Error Rate Testing

12. Medicare Outpatient E&M Allowables

13. Basic Concepts

14. Principles of Medical Record Documentation The physician or other billing provider note only valid support for billing of most professional services

15. Medical Coding Basics Diagnosis International Classification of Diseases (ICD-9CM) World Health Organization Procedure Current Procedure Terminology (CPT) American Medical Association Supply and interim codes Healthcare Common Procedure Coding System (HCPCS) Payer-specific and specialty-specific coding systems

16. Medical Record Documentation Should include Reason for the encounter (Chief Complaint) is always required Relevant history Physical exam findings and prior diagnostic test results Assessment, clinical impression or diagnosis Plan for care Date and legible identity of clinician

17. Evaluation and Management (E&M) Codes

18. E&M ClassificationsSvcs underlined are subject to Medicare guidelines Office or Other Outpatient Hospital Observation Hospital Inpatient Consultations Emergency Department Critical Care Neonatal Intensive Care Nursing Facility

19. E&M Services Classifications – most common Outpatient - clinic visits Consult New Established Inpatient – hospital visits Initial Subsequent Consult, initial and follow-up

20. Categories of Service

21. Medicare Outpatient E&M Allowables

22. New or Established Patient New patient: has not received any professional evaluation and management (E&M) services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years Established patient: has received an E&M service from group within three years

23. Consultation Subcategories Office Inpatient Initial Inpatient Follow-up Confirmatory

24. Consultations A Consultation is an E&M service provided by a physician whose opinion and advice is requested by another physician or appropriate source Consultations should be viewed as a three-part cycle (1) a request is made (2) an evaluation is undertaken and (3) an opinion is rendered and sent to the requesting physician. The consultant may initiate diagnostic and/or therapeutic services at the same visit.

25. If ongoing care of a particular condition is assumed in advance, service is not a consult but a new/est. patient visit Consultations

26. Consult Documentation Requirements Written or verbal request must be documented. As an example: “Mr. Jones seen in consultation at the request of Dr. Smith.”

27. Confirmatory Consultations A consultation initiated by a patient and/or family Third party payer required second opinion

28. Levels of Service

29. Defining Levels of Service History Physical Examination Medical Decision Making Other Considerations

30. History – Three Parts History of Present Illness Review of Systems Past, Family and Social History

31. History of the Present Illness (HPI) Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

32. Two Levels of HPI Brief = 1-3 elements described Extended = 4+ elements described OR Status of at least 3 chronic or inactive conditions

33. Review of Systems (ROS) An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had.

34. Review of Systems (ROS)

35. Past, Family and Social History (PFSH)

36. Two Levels of PFSH Pertinent: one of the three areas Complete: document specific item from all three areas Complete for established patients: two of three areas is sufficient

37. Four Levels of History Problem focused Brief HPI Expanded problem focused Brief HPI, Pertinent ROS, no PFSH Detailed Extended HPI and ROS, 1 PFSH element Comprehensive Extended HPI, Complete ROS and PFSH

38. 2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp 102-103. Vomited 2X this a.m., ? appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare History Example

39. 2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp 102-103. Vomited 2X this a.m. ? appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare History Example

40. History Example 2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp 102-103. Vomited 2X this a.m. ? appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare

41. History Documented in Example Chief Complaint Always required HPI, 4 descriptors Extended ROS, 4 systems Extended PFSH, social (1) Pertinent Detailed

42. Documenting the Physical Exam A general multi-system exam or any single organ system exam may be performed by any provider. The type and content are selected by the provider depending upon medical necessity. Note specific abnormal & relevant negative findings of the affected or symptomatic area(s)--“abnormal” is insufficient. Describe abnormal or unexpected findings of asymptomatic areas or systems. Noting “negative” or “normal” is sufficient to document normal findings in unaffected areas.

43. Physical Exam Guidelines (1995) Problem Focused A limited examination of the affected body area or organ system Expanded Problem Focused A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Detailed An extended examination of the affected body area(s) and other symptomatic or related organ systems Comprehensive A general multi-system examination (8 or more of the 12 systems) or complete examination of a single organ system

44. General Multi-system Exam (1997) Problem Focused Documentation of 1-5 elements Expanded Problem Focused At least 6 elements One or more organ/body system Detailed at least 6 organ/body system covered for each system/area, at least 2 elements noted OR At least 12 elements total 2 or more organ/body systems Comprehensive At least nine organ systems/areas covered For each, all elements should be performed Document at least 2 elements in each system/area

45. Single Organ System Examination Requirements for elements documented similar to 1997 multi-system Single organ system exams for the following:

46. Medical Decision Making (MDM) Based on: Number of Diagnostic and/or Management Options Amount and Complexity of Data Risk

47. Medical Decision Making Elements Diagnostic and/or management options (max = 4 “points”) Self-limited, minor (1 ea) Established problem stable, improved (1 ea) Established problem worsening (2 ea) New problem, no add’l workup planned (3 ea) New problem, add’l workup planned (4 ea)

48. Medical Decision Making Elements Amount & complexity of data (max = 4 points) Review/order of clinical lab, radiologic study, other non-invasive diagnostic study (1 ea type) Discussion of diag study w/interpreting phys. (1) Independent review of diagnostic study (2) Decision to obtain old records or get data from source other than patient. (1) Review/summary old med records or gathering data from source other than patient (2)

49. Medical Decision Making Elements Risk (last page of handout) Presenting problem Diagnostic procedures Management options

50. Table of Risk see the last page of the handout

51. Level of MDM

52. Note on Establishing MDM Co-morbidities and 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.

53. New Outpatient Visits/Consults

54. Established Outpatient Visits

55. Initial Hospital/Observation

56. Subsequent Hospital and Follow-up Consults

59. Documenting Time-based Coding If time spent counseling and/or coordinating care is more than 50% of encounter, use time May count TP face-to-face time only for OP, coordination, time on floor for IP Document amount of time counseling and total time spent on encounter and describe counseling, coordination activities Document only minimal history, exam OR medical decision making

60. Time as the Controlling Factor

61. Examples of Time-based Codes Critical care Other E&M visits where >50% counseling Individual psychotherapy codes (non E&M) Prolonged services

62. Append a modifier 25 to an E&M code if a significant, separately identifiable E&M service is performed by the same physician on the same day of a procedure or other service. The patient’s condition must require E&M services above and beyond what would normally be performed in the provision of the procedure. The necessity for the E&M service may be prompted by the same diagnosis as the procedure. A new patient E&M service is considered separate from the same day surgery or procedure—no 25 modifier needed. Modifier 25

63. For an established patient, if the E&M service resulted in the initial decision to perform a minor procedure (0-10 days global period) on the same day and medical necessity indicates an E&M service beyond what is considered normal protocol for the procedure, the 25 modifier is appropriate. To determine the correct level of E&M service to submit, identify services unrelated to the procedure and use as E&M elements. Clearly mark the encounter form to indicate that a 25 modifier should be attached to the E&M. Modifier 25

64. E&M–Teaching Physician (TP) Documentation Requirements

65. Proper Teaching Physician Attestation The 11/22/02 revisions to the regulations provide that, for E&M services, the TP does not have to duplicate any resident documentation. The TP must be present during the key portions of the service and personally document his or her presence.

66. The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed. Documentation by a resident of the presence and participation of the TP is not sufficient. Documentation may be dictated and typed, hand-written or computer-generated. Proper Teaching Physician Attestation

67. Examples of Acceptable TP Notes Admitting Note: "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care." Initial or Follow-up Visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note. *Complete regulations and scenarios from CMS: http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf Or http://www.med.unc.edu/compliance/CMS_TP_RegRev/welcome.htm

68. Examples of Acceptable TP Notes Follow-up Visit: "I saw the patient with the resident and agree with the resident's findings and plan. Initial or Follow-up Visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note.“ Follow-up Visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written." *Complete regulations and scenarios from CMS: http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf Or http://www.med.unc.edu/compliance/CMS_TP_RegRev/welcome.htm

69. Examples of Unacceptable TP Notes "Agree with above." followed by legible countersignature or identity; "Rounded, Reviewed, Agree." followed by legible countersignature or identity; "Discussed with resident. Agree." followed by legible countersignature or identity; *Complete regulations and scenarios from CMS: http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf Or http://www.med.unc.edu/compliance/CMS_TP_RegRev/welcome.htm

70. "Seen and agree." followed by legible countersignature or identity; "Patient seen and evaluated." followed by legible countersignature or identity; and A legible countersignature or identity alone. *Complete regulations and scenarios from CMS: http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf Or http://www.med.unc.edu/compliance/CMS_TP_RegRev/welcome.htm Examples of Unacceptable TP Notes

71. Exception for Primary Care TP may supervise up to 4 residents on immediately available basis Review each patient case during or right after visit TP must document extent of participation by writing a note documenting his/her contemporaneous discussion of the patient’s condition with the resident. Approved primary care centers at UNC: Family Medicine, General Medicine, General Pediatrics, Women’s Primary Health Applies to E&M codes 99201-03, 99211-13 Residents must have completed 6 months training

72. Procedures – TP Documentation

73. Procedures TP must be present during critical and key portions & immediately available throughout Surgical procedures Endoscopic operations TP decides what portions are key If present entire time, resident note can attest If present for key portions only, TP must document extent of involvement

74. Procedures Two overlapping surgeries Key portions must happen at different times Must be available to return to either Minor procedures of <5 minutes Must be present the entire time Endoscopies (other than surgical operations) TP must be present for entire viewing including insertion and removal

75. Radiology/Diagnostic Tests Image and resident interpretation must be reviewed by TP to be billable TP may sign acknowledging agreement or edit, co-signature insufficient

76. Psychiatry TP presence requirement met by concurrent observation of the service by video or one-way mirror Must be present for entire period of time billed if time-based psychotherapy code is used

77. Other procedures Time-based procedures billed on TP time only Critical care Hospital discharge day management Prolonged services Care plan oversight E&M counseling/coordination of care Specific complex or high-risk procedures require personal TP supervision Interventional radiologic/cardiologic codes Cardiac cath, stress tests, transesophageal ekg

78. Procedures TP must be present during critical and key portions & immediately available throughout Surgical procedures Endoscopic operations TP decides what portions are key If present entire time, resident note can attest If present for key portions only, TP must document extent of involvement

79. Coding Checklist

80. 1. Is the type of visit: New? Established? Consult? Confirmatory (usually insurance-related) consult? Coding Checklist for E&M Services

81. 2. Is the level of visit: Medically necessary? Performed? Documented? Coding Checklist for E&M Services

82. 3. If the level of visit is to be based on time, is the time spent in counseling and/or discussion of the treatment plan greater than 50% of the total visit, and is the total visit time documented? Coding Checklist for E&M Services

83. 4. Is there a note by the TP documenting involvement in each of the key portions of the visit? Coding Checklist for E&M Services

84. 5. If the visit is under the primary care exception, is there a note indicating the TP discussed the visit with the resident, concurred or supplemented the note as needed? Coding Checklist for E&M Services

85. 6. Is the providing physician, the documenting physician and the billing physician the same person? Is the encounter form clearly marked as to provider? Coding Checklist for E&M Services

86. 7. If there was a procedure and there was a separately identifiable evaluation and management service on the same day, is the E&M code billed with the “25 modifier” box on the encounter form checked/circled? Coding Checklist for E&M Services

87. New patient 99204 Initial office visit for a 17-yr-old female with depression Initial office visit for initial evaluation of a 63-yr-old male with chest pain on exertion Initial office visit for evaluation of 70-yr-old patient with recent onset of episodic confusion. Clinical Examples

88. Established patient 99213 Office visit for a 62-yr-old female, established patient, for follow-up for stable cirrhosis of the liver. Office visit for a 60-yr-old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check. Office visit for a 50-yr-old female, established patient, with insulin-dependent diabetes mellitus and stable coronary artery disease, for monitoring. `Clinical Examples Clinical Examples

89. Established Patient 99214 Office visit for a 28-yr-old male, established patient, with regional enteritis, diarrhea, and low-grade fever. Office visit for a 28-yr-old female, established patient, with right lower quadrant abdominal pain, fever, and anorexia. Office visit with 50-yr-old female, established patient, diabetic, blood sugar controlled by diet; complains of frequency of urination and weight loss, blood sugar of 320 and negative ketones of dipstick. Clinical Examples

90. Established Patient 99215 Office visit with 30-yr-old, est. patient, for 3- month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. Office visit for evaluation of recent onset syncopal attacks in a 70-yr-old woman, est. patient. Office visit for a 70-yr-old female, est. patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation and short-term memory loss. Clinical Examples

91. Other credentialing requirements - reminder Hospitals multi-topic post-test for new attendings HIPAA certification If you have not completed these two items, please visit www.med.unc.edu/credentialing/

92. Where To Get Help www.med.unc.edu/compliance/ UNC P&A Professional Charges 962-8391 School of Medicine Compliance Office 843-8638 Charles Foskey, Compliance Officer Chris Carreiro, CPC Office Manager Heather Scott, CPC, Compliance Auditor Wendy Smith, CPC, Compliance Auditor Confidential Help Line 800-362-2921 AMA CPT Manual

93. A group review and quiz on coding and compliance…

94. Coding and Compliance Quiz True/False. Medicare pays residents and fellows through Part A and therefore does not pay for services provided when a teaching physician is not physically present at the time the service is rendered.

95. Coding and Compliance Quiz For time-based codes, such as critical care, prolonged services, individual medical psychotherapy, or E&M services for which time is considered the controlling factor in selection of code, the TP must: Be physically present for the entire period for which the claim is made and must personally document his/her presence for the entire time being billed. Be present for the key portions of the service and the resident may document his/her presence. Be present for the key portions of the service and must personally document his/her presence

96. Coding and Compliance Quiz True/False. An established patient visit requires only two of the following to be documented: history, physical exam, medical decision making.

97. Coding and Compliance Quiz Which of the following apply to Medicare’s Primary Care exception? If the resident has had six months of residency training, s/he may see the patient alone and bill a low level (levels 1-3) new or established patient visit in the teaching physician’s name. The TP must be present during the key portions of the exam. At the time of the visit or immediately after, the resident and TP are required to discuss the patient’s visit. The TP may supervise up to five residents at one time. b and d a and c a and d

98. Coding and Compliance Quiz Medicare’s documentation requirements can be met by: Co-signatures and such statements as “agree with above” or “seen and agree.” Full note by TP or documentation in addition to the resident’/fellow’s note by the TP that demonstrates his/her participation in the required key elements of the history, exam and medical decision making. A computer-generated note stating, “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written.” b or c

99. Coding and Compliance Quiz True/False. The 11/02 CMS revisions to the teaching physician requirements were meant to ease the burden of the TP. As such, resident statements indicating the TP presence during key portions of the exam is sufficient when coupled with a countersignature.

100. Coding and Compliance Quiz True/False. If after an initial outpatient consultation, the patient returns to the clinic for follow up, another consult code may be billed.

101. Coding and Compliance Quiz For major surgery cases and most procedures requiring over five minutes to perform, the TP can: Be present with the resident during the entire procedure and have h/her presence documented by the resident’s note. Be present with the resident during the key portions of the surgery and be immediately available during the entire procedure. The documentation may be by the TP, the resident or a nurse. Be present with the resident during the key portions of the surgery, be immediately available during the entire procedure, and personally document h/her presence including the key portions for which h/she was present. a and b a and c

102. Coding and Compliance Quiz For endoscopies and similar procedures, the TP must: Be present during the entire viewing (including insertion and removal). The resident may document the TP’s presence. Be immediately available, but may view the procedure through a monitor while in another room. The TP must personally document. May be present at the key portions of the procedure and must personally document h/her presence. a or c

103. Coding and Compliance Quiz True/False. The following is considered to be an acceptable TP attestation for a new patient. “I performed a history and physical exam of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

104. Coding and Compliance Quiz Elements that distinguish a consultation from other types of E&M services include: A physician or other appropriate source requests the consultant’s opinion, advice or evaluation of a particular problem and the request is documented in the patient’s medical record. The requester doesn’t assume that the consultant will undertake management of the patient’s condition, although the consultant may initiate diagnostic or therapeutic services at the initial visit and may decide to manage the patient for that condition. The consultant’s opinion or advice must be communicated to the requesting physician. All of the above.

105. Coding and Compliance Quiz Time may be used to determine the level of E&M service if: More than 50% of the encounter is spent providing counseling and the note so states. The total amount of time is documented in the medical record. The requirement for the history, examination and medical decision making are also met for the level of service. a & b b & c

106. Coding and Compliance Quiz True/False. If a patient was seen by Dr. Jones of UNC Cardiology two years ago and returns to see a different UNC cardiologist, the patient is considered new.

107. Coding and Compliance Quiz Providing good care while billing accurately and confidently requires: Always getting an extensive review of systems. Doing what is medically necessary. Documenting what you do. Billing what you document. a, b and c b, c and d

108. Coding and Compliance Quiz Which of the following scenarios with Medicare patients may require refunding and possibly payment of a fine to the federal government? The TP sees the patient, discusses the patient with the resident and co-signs the resident note. The TP performed and billed the medically necessary level of E&M service for a new patient. The documentation didn’t include all the details of the medical exam to support the billed level of service. A physician or other provider saw a patient last seen by the practice 38 months ago and bills a new patient visit. a and b All of the above

109. Coding and Compliance Quiz Guidelines for billing an E&M visit and procedure on the same day of service include: -25 modifier must be attached to the E&M code. Both services are billable only if the diagnosis for the E&M is different from the diagnosis for the procedure. The procedure and the E&M visit may both be billed by the same diagnosis code and during the same encounter, if the patient’s condition requires a significant, separately identifiable E&M service beyond the usual care associated with the procedure. a and c a and b

110. Coding and Compliance Quiz True/False. A new patient visit and a consultation must be documented at the level of service coded in all three areas: history, physical exam and medical decision making unless it is billed based on time spent in counseling.