Medicare Payments to Physicians

1. Medicare Payments to Physicians Charles F. von Gunten, MD, PhD, FACP Medical Director, Center for Palliative Studies San Diego Hospice Associate Clinical Professor of Medicine University of California, San Diego

2. Major Topics • Coding • Documentation • Reimbursement

3. Case Example… • You are asked to see a woman with dyspnea, nausea and chest pain.

4. Video Trigger Tape from EPEC Module 10 www.epec.net

5. Coding for physician services • 2 Codes • CPT Procedure/Service Code • ICD-9-CM Diagnosis Code • Fee • Physician Fee • Payer’s fee schedule • Permissible co-payment • Total income reflects payer mix

6. CPT Codes • Current Procedural Terminology Source for all physicians, published by AMA Evaluation and Management Codes (99201-99499) History Physical Examination Decision-making Counseling/Information

7. Coding by Components • History Limited vs Extensive • Physical Examination Limited vs Extensive • Decision-making Straightforward vs serious

8. Counseling/Information • If more than 50% of a patient/physician interaction is comprised of counseling and information giving, then time can be used to determine which E/M code is used • Inpatient, total time on unit • Outpatient, total face-to-face time

9. Case Example… • 4 pm walk on unit, review chart, interview and examine patient, discuss diagnosis and prognosis. • 5 pm. Reviewed radiographs. Discussed with pulmonology, cardiology, cardiac surgery. Discuss w/ attending, nursing staff. Returned to discuss findings with patient for additional 30 minutes. Then documented in medical record • 6:30 pm complete.

10. …Example • You spend an additional 30 minutes obtaining consent, assembling the supplies, performing the procedure, and documenting this in the chart.

11. …Example • 150 minutes total time on unit. • 90 minutes face-to-face with patient. 60 min. related to information giving and counseling. • Recommend morphine for dyspnea and therapeutic thoracentesis for pleural effusion.

12. Initial Inpatient Consultations (hospital or nursing home)

13. Prolonged ServiceFace-to-Face

14. Case example coding • CPT E/M Code • 99255 (110 min) • 99356 (40 min) • Diagnosis Code

15. ICD-9-CM diagnoses

16. Concurrent Care • 2 physicians providing care to the same patient on the same day • Permitted • Coding reflects the differences • Documentation supports the codes and describes the need and services provided

17. Concurrent Care • Document care provided • Use different ICD-9-CM codes

18. Concurrent Care Coding Example • Woman with pulmonary fibrosis, aortic aneurysm, dyspnea In addition, CPT Code for paracentesis and ICD-9 code for pleural effusion if it is done by consultant

19. Subsequent Visits • Follow-up Consultation Codes are only used to complete the consultation • If you are managing all or a portion of the patient’s care, use attending/managing physician codes

20. Time vs Complexity • How do I decide? • Answer: Which ever one best describes the work you did.

21. Major Topics • Coding • Documentation • Reimbursement

22. Documentation • Medical Record is the primary resource to support codes for physician billing • Include all elements that support the selected code • If using time, explicitly indicate time taken and what you did during that time.

23. Documentation • Name of referring physician • Reason for the consultation • Summary of your findings • Recommendations • Time spent (code) • Counseling/Information Giving

24. 68 year old woman with dyspnea, nausea near the end of her life. Medical Record by MD: Feeling a bit better. VS Stable. CPM Documentation in palliative care

25. Some palliative care domains • Patient/Family Unit • Physical • Psychological • Social • Spiritual • Team

26. Severity of IllnessIntensity of Service • Hang Crepe (in the chart) • Why is the patient so sick as to require the current setting (and expense)? • Why do you need to be there?

27. Documentation Pearls • Describe the whole picture • Describe barriers to plan implementation • Clearly state your assessment and plan • In my medical judgment • In my medical opinion

28. Compare/Contrast • “The patient is a little weaker today, prognosis grim, continue present comfort measures”

29. Compare/Contrast • Rapid and precipitous decline since last visit. Now bed bound. Cognition is markedly worse. Blood pressure and urine output have declined. Indicates severe organ failure in at least the cardiac, GI, GU, musculoskeletal, and neurological systems.

30. The wife, 3 daughters, 4 grandchildren and 6 siblings are highly distressed requiring extensive counseling and information giving in the presence of the patient • Extensive discussions with nursing, social work and chaplaincy to coordinate care

31. In my medical judgment, the patient will die in 72-96 hours. • It is unwise to move him to another setting. • The acuity of need is high. The patient requires around-the-clock RN care and frequent MD visits in order to monitor and respond to changes in condition.

32. Major Topics • Coding • Documentation • Reimbursement

33. After coding (and documentation), what next? • Coding/Billing Office • Payer • Review • Payment • Denial

34. Balance of Interests • Three players • Payer Pay only for needed services • Physician (documentation) Reimbursed for work done • Billing/Collection Get work done and minimize stress

35. Medicare Part B • Regional Carrier • Interprets Rules and Instructions • Denial of Payment • Technical • Substantive

36. Physician • Adequate documentation • Legible • “Too busy” • “Just want to care for patients” • Arrogance

37. Billing Office • Responds to Threats and Rewards • “Get the bills out” vs“Maximize receivables” • Relationship with Accounts Receivable

38. Medicare Fee Schedule • Resource-Based Relative Value Scale (RBRVS) • (Measure of effort) x (Conversion Factor determined each year) • Participating physicians get 80% when they bill Part B • Required copayment for participating physicians

39. Codes and Reimbursement Northwestern Faculty Foundation 1995 Northwestern Faculty

40. Burden of appeal • Physician • Track denials • Rewards • Communicate with payers

41. Palliative Care • No special codes (no special rules)

42. Medicare Hospice Benefit • Attending Physician Bills Part B in usual fashion Cannot be associated with the hospice in medical director or hospice medical director capacities (even voluntarily) Attests to independence Paper Claim on HCFA 1500 claim form (source of technical denial) or Electronic Claim (EMC) include HC modifier to CPT code

43. Hospice Medicare Benefit • Hospice Medical Director Administrative/supervisory activities included in the per diem rate Direct Patient Care Services billed fee-for-service to the hospice agency The hospice agency submits the codes for reimbursement under Part A

44. Medicare Hospice Benefit • Physicians Associated with the hospice (even volunteers) Submit claims to Hospice for submission to Part A • Consultants Submit claims to Hospice for submission to Part A Requires a contract with the hospice

45. Conclusions • Code for palliative care using standard physician coding • Document adequately—hang crepe and clearly state your medical judgment. • Reimbursement is influenced by behaviors in billing/accounts receivable department.