PCLC Curriculum Module 2

1. PCLC CurriculumModule 2 2012 Update

2. Content Authorship The following are authors and reviewers of this content: Authors • David E. Weissman, MD • Julie Pipke, CPC Reviewers • Brian Cassel, PhD • Lyn Ceronsky, MS, APRN • Sandra Muchka, RN, MSN, CHPN • Vyjeyanthi S. Periyakoil, MD • Jennifer Raiten, LMSW • Lynn Spragens, MBA The content of this course was adapted from presentations during the June 2007 CAPC Level II Seminar as developed by Martha Twaddle, MD, and Constance Dahlin, APN, BC, PCM. Special thanks to Christine Santiago, CPC, CPC-H, for reviewing this course. The content of this course was updated August 2012.

3. Learning Objectives • Distinguish two methods of billing for palliative care consultations: time vs. complexity • Describe three requirements for APN billing in the hospital setting • Demonstrate effective work habits with your billing/coding specialist

4. Introduction Accurate and thorough billing practices can provide substantial financial support for your program. This course will focus on billing for inpatient palliative care consultations. Except where indicated, all content is equally applicable to physicians and advance practice nurses.

5. Warning! Billing rules change frequently! This presentation is current as of July 2012. Billing rules and practices vary among regions, states and institutions. Check with your own qualified billing/coding professionals and medical staff bylaws (especially important for APN billing) to ensure that proper documentation standards are met.

6. Part A: Billing for Palliative Care Consultations in Hospital Settings

7. Definitions: Consultation and Referral Consultation A service which renders professional advice, opinions or recommendations Referral The transfer of total care or a specific part of care from one physician to another

8. Palliative Care Consultation Four requirements for a billable consultation: 1.Written request for consultation from an appropriate source The AMA's definition of an appropriate source is: a physician, physician assistant, a nurse practitioner/clinical nurse specialist, a doctor of chiropractic medicine, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer or insurance company.  2.Reason for consultation 3.Provision of the consultation service • Written report to requesting physician/provider with recommendations. Not required for inpatient or ER consultations due to the shared medical record.

9. Example: A Written Palliative Care Consult Referring physician/provider writes: “Consultation request to palliative care for assistance in pain assessment and management for Ms. Jones.” Consulting physician/provider writes back in written report: “I was asked by Dr. Smith to consult on Ms. Jones for assistance with pain assessment and management.”

10. Billing for a Consultation There are two parts to the equation: Part 1. Procedure description using CPT codes • Evaluation and Management (E&M codes) and/or • Procedure codes (e.g., paracentesis) Part 2. Diagnosis description using ICD-9-CM codes • Symptoms, physical findings, chief complaints • Final diagnosis • Reason for encounter

11. E & M Codes Criteria for determining which code to use: • Site of service (e.g., inpatient, home, outpatient) • Intensity/complexity of patient care • Time spent providing service • Role of the physician: attending vs. consultant • Payment source (Medicare vs. other)

12. CMS Eliminates Payment for Consults • Effective 1-1-10 Medicare will no longer reimburse providers for “consultations”, performed in any setting. • Inpatient consultations under Medicare will now be billed as initial patient visits (see Slide 14). • Commercial carriers and some Medicare HMO’s will continue to reimburse providers for consultation CPT codes; review your individual contracts. • Providers and billing offices need to develop a plan to deal with this major change.

13. RVU’s Increase for Other E/M Services • In an effort to redistribute the resulting savings to increase payments for the existing evaluation and management (E/M) services, CMS has increased the RVU’s for other E/M services. • Initial Inpatient (99221-99223) • Subsequent Inpatient (99231-99233) • New (99201-99205) • Established (99211-99215)

14. Hospital Consultation E & M Codes Initial Visit (Non Medicare)Medicare Cross Code 99251 99231 99252 99232 99253 99221 99254 99222 99255 99223 Subsequent Visits 99231 99232 99233

15. Distinguishing Inpatient Services • Both the attending physician and the consulting physician may be billing for their services with the same CPT codes (99221-99223). • CMS has created the “AI” modifier to be appended to the attending physician’s CPT code to differentiate their service from services of consultants.

16. Determining Level of Service Choice of service level can be made according to one of two criteria: Complexity or Time

17. Billing by Complexity ComplexityChoice of service level is based on the degree of work, medical complexity and documentation of each three key components: 1. History 2. Physical examination 3.Decision making The specific documentation standards to justify billing at the different service levels are beyond the scope of this course. However, most palliative care consultations will require complex medical decision making, based on a comprehensive history and exam, justifying high service levels: 99254–99255 (non-Medicare) 99222-99223 (Medicare)

18. Common Consults and Complexity Examples

19. Billing by Time for Inpatient Services • Each E & M service code is associated with an amount of time (see next page for further explanation). • Unit/floor time includes both provider presence on the patient’s hospital unit and at the bedside rendering service for that patient.

20. Time-Based Coding and Billing Palliative care encounters with patients frequently involve multiple domains of whole-person palliative care. Much of our time is spent: • Coordinating differing medical opinions • Counseling and educating patients and families • Formulating and communicating prognosis and goals of care • Exploring burden/benefit of various approaches to the patient’s goals of care

21. What counts as “time”? • Reviewing current and old records • Patient interview and examination • Writing notes • Communication with other professionals • Communication with families Note:When billing outpatient E/M services based on time, only time spent face to face with the patient can be used to determine the level of service. When using prolonged-service codes (see page 28) and billing for outpatient work, only face-to-face time with the patient counts toward time-based billing service levels. Provider’s must document IN and OUT times in the medical record when they are billing for inpatient prolonged care.

22. Time-based Billing:Initial and Subsequent Hospital Visits Initial Visit Non-MedicareMedicare 99251 20min 99231 15 min 99252 40min 99232 25 min 99253 50min 99221 30 min 99254 80min 99222 50 min 99255 110min 99223 70 min ____________________________________________________________________________________________________________ Subsequent Visits 99231 15min 99232 25min 99233 35min

23. What counts as “counseling”? Discussions involving the following: • Diagnostic results, impressions and/or recommended diagnostic studies • Prognosis • Risks and benefits of management or treatment choices • Instructions for management (treatment and/or follow-up) • Importance of compliance with chosen management (treatment) options • Treatments initiated or adjusted • Risk factor reduction • Patient and family education

24. Prolonged-Service Codes When the time spent for hospitalized patients is greater than that associated with the routine codes (page 23), prolonged-service codes can be used. NOTE: The additional time must be face-to-face for Medicare; for other payors, floor/unit time is sufficient Patient is present (All payors) 99356: first hour of prolonged service99357: each subsequent 30 minutes Patient notpresent (Medicare) 99358: first hour of prolonged service 99359: each subsequent 30 minutes Patientnotpresent (Non Medicare) 99356 & 99357

25. Threshold Table for Inpatient E/M

26. The Family Meeting • The family meeting, with or without the patient present, is a common palliative care “procedure.” • Family meetings are often billed on the basis of time. • Billing rules depend on whether or not the patient is present for the meeting.

27. Scenario #1: Patient is present At time of initial consultation: • Non-Medicare: • Use: 99251–5 + 99356–7. • Medicare: • Use: 99221-99223 or 99231-99232 + 99356-7 At time of subsequent visit: • All Payors • Use: 99231–3 + 99356–7

28. Scenario #2: Patient is notpresent At time of initial consultation: • Non- Medicare • Use: 99251–5 + 99356–7 • Medicare: • Use: 99221-99223 or 99231-99232 + 99358-9 At time of subsequent visit: • All Payors • Use: 99231–3 + 99358–9 for prolonged service. Note: Medicare does not reimburse for 99358–9 codes (patient not present, prolonged service). However, RVU’s are still associated with these codes.

29. Prolonged Service with Surrogates • Many family meetings are held solely with the patient’s representative (surrogate) when the patient is not decisional. • However, AMA and Medicare are silent on whether or not a patient’s representative can be considered equivalent to the patient, and thus meet the standard of face-face contact. • To avoid a potential audit, you should check with your Medicare carrier or insurance company. If they decide that you may not use 99356–57, it is worth appealing the decision.

30. Consultations in the Emergency Department • Use the following codes when the palliative care consultation service is asked to see a patient in the ED: Non-Medicare 99241-99245 Medicare 99281-99285

31. Concurrent Care Concurrent care by two or more physicians from the same specialty, on the same day of service, is no longer reimbursable by Medicare. Medicare only allows payment to one provider of a recognized specialty per day. This means only one NP or PA will be reimbursed per patient, per day. Medicare no longer allows the use of the 77 modifier for E/M services. Previously this modifier was allowed to signify that two providers of the same specialty were seeing the patient for unrelated reasons.

32. Summary of 2010 Medicare Billing Changes • Follow the link for a 7 minute video that reviews the new 2010 billing rules. http://emuniversity.com/consultinfo.html

33. ICD-9-CM • Codes describe the reasons for physician services. • Codes are updated annually. • Both diagnosis (pneumonia) and symptom codes (dyspnea) are available. • Many palliative care consultations can be defined by symptom codes, thus differentiating palliative care service from another specialist who uses a disease code.

34. Example: Consult for Dyspnea Management

35. Part B: APN Billing for Palliative Care Consultations in Hospital Settings

36. APN Billing Advance Practice Nurse includes: • Nurse Practitioner (NP) and • Clinical Nurse Specialist (CNS) • Doctor of Nursing Practice (DNP) Rules about billing vary: • By state • Between NP and CNS in some states; in others, they are treated the same Note:Check with your state board of nursing for specific billing requirements/information. Review hospital bylaws regarding APN billing.

37. Hospital Consultations Medicare allows NP/CNS billing, under a unique billing number, for inpatient consultations. If billing under own APN name: • No supervisory note by physician is required. • No physician co-signature is required (although some facilities may require a supervising physician signature; check your facility requirements).

38. APN Billing Requirements The following requirements must be met: • The APN meets Medicare qualification requirements. • The services are within the APN scope of practice as defined in state law. • The practice or facility accepts Medicare’s payment of 85% of the physician rate. • The services performed are “physician services” or those for which a physician can bill Medicare. • The services are performed in collaboration with a physician. • No facility or other provider charges are paid with respect to the furnishing of the services.

39. APN Billing Requirements (cont’d.) • Master’s , or Doctor of Nursing Practice Degree • RN license in state where providing services • Meet state Advanced Practice statutes • Medicare Provider Number (was UPIN, now NPI) • Source of salary not from a hospital fund* *Note: Hospitals may bill for APN services (Medicare B) only if they do not list the APN as part of the Medical Part A Cost Report.

40. Medicare-Approved APN Certification Bodies Please visit the following Web sites for more information: • National Board for Certification of Hospice and Palliative Nurses • American Academy of Nurse Practitioners • American Nurses Credentialing Center • AACN Certification Corporation • Pediatric Nursing Certification Board • Oncology Nurses Certification Corporation • National Certification Corporation for OB, GYN and Neonatal Nursing Specialties

41. Requirements for Obtaining Medicare Provider Number • Master’s or DNP degree after 2003; NPs without this were “grand-fathered” in. A CNS must have a master’s degree by definition of practice. In other words, a CNS needs to have appropriate scope of practice and appropriate education. • Recognized by State Practice Act • Certified by national body within specialty • Works in collaboration with physician as defined by CMS

42. Definition: Collaboration The process in which the APN works with one or more physicians to deliver health care services within the scope of the practitioner’s knowledge, with medical direction and suitable supervision as provided for in jointly developed guidelines and or other mechanisms. The collaborating physician does not have to be in attendance with the NP when services are furnished or to construct an independent evaluation of each patient who is seen.

43. Definition: Shared Visit • When an E/M service is a shared/split encounter between a physician and an AHP (NP, CNS, CNM or PA) from the same group practice… • Both providers must provide a face-to-face portion of the E/M service and each must document their portion in the medical record. • The physician’s documentation should provide details of his/her face to face interaction with the patient. A mere attestation statement “seen examined and agree with NP/PA” is no longer acceptable (Medicare-WPS).

44. Putting It All Together 1. Meet with your qualified billing/coding specialist to: • Describe the services you will be providing • Provide resource information about palliative care billing • Inquire about local/regional issues concerning APN billing and concurrent billing • Ask for assistance in developing a documentation template • Review hospital bylaws for APN billing

45. Putting It All Together (cont’d.) • Develop a documentation template, ideally as part of a consultation assessment tool. See this link for supporting resources and sample assessment tools: http://www.capc.org/tools-for-palliative-care-programs/billing/ • Develop a quality improvement strategy to monitor your billing practices that includes regular communication with your billing/coding specialist. • Learn about the charge capture process and be a resource for billing issues (e.g., denials, appeals, etc.).

46. Summary • Proper documentation is the key to successful billing. • Palliative care billing requires a thorough understanding of applicable E & M codes, with special attention to the use of time-based billing codes. • APNs, either an NP or CNS, can bill for palliative care services. • A close working relationship with your qualified billing/coding specialist is essential.

47. Additional Resources 1.Billing Tools.Center to Advance Palliative Care, 2008. Visit: http://www.capc.org/tools-for-palliative-care-programs/billing/ 2.Meier DE et al. A Guide to Building a Hospital-Based Palliative Care Program. New York: Center to Advance Palliative Care; 2004. To order: click here 3.AMA CPT coding information online https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp 4.ICD-9 information online http://en.wikipedia.org/wiki/List_of_ICD-9_codes

48. Additional Resources (cont’d.) 5.Medicare-approved APN certification organizations: • American Academy of Nurse Practitioners • National Board for Certification of Hospice and Palliative Nurses • American Nurses Credentialing Center • AACN Certification Corporation • Pediatric Nursing Certification Board • Oncology Nurses Certification Corporation • National Certification Corporation for OB, GYN and Neonatal Nursing Specialties

49. References • Campbell M, Dahlin C. Advanced practice palliative nursing: A guide to practice and business issues. Pittsburgh, PA: HPNA, 2008. http://www.hpna.org/Item_Details.aspx?ItemNo=978-1-934654-05-7 • Buppert C. Does physician billing for hospital-based nurse practitioner visits violate the Stark law? Medscape Nurses. 2009. Available at: http://www.medscape.com/viewarticle/589413 • Buppert C. Nurse practitioner's business practice and legal guide. 3rd ed. Sudbury, MA: Jones and Bartlett, 2008. • Fowler NM, Lynn J. Potential Medicare reimbursements for services to patients with chronic fatal illnesses. J Palliat Med. 2000 Summer;3(2):165–80.

50. References (cont’d.) • Frakes MA, Evans T. An overview of Medicare reimbursement regulations for advanced practice nurses. Nurs Econ. 2006 Mar–Apr;24(2):59–65, 55. • von Gunten CF, Ferris FD, Kirschner C, Emanuel LL. Coding and reimbursement mechanisms for physician services in hospice and palliative care. J Palliat Med. 2000 Summer;3(2):157–64. • www.cms.gov Documentation Guidelines for Evaluation and Management Services. 2003 most recent update. • Department of Health &Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare &Medicaid Services (CMS) Transmittal 1875; December 14, 2009.