Indiana Rural Health Association

1. IndianaRural Health Association Annual Conference Accurate Coding for the Rural Health Clinic Janet Lytton, Director of Reimbursement Rural Health Development 308-647-6455 janet.lytton@rhdconsult.com Indianapolis, Indiana June 2012

2. OBJECTIVES Understand what CPT codes are split and why within the RHC Assure clinic is not missing any chargeable codes Assure clinic is coding preventive services correctly

3. CODING DOES NOT CHANGE Independent Rural Health Clinic Provider Based Rural Health Clinic Coding does not change for the various provider types RHC is a payment methodology and not a difference in coverage * ICD-10 delayed implementation to 10/1/2014

4. Coding Levels of Care DOES IT MATTER HOW WE CODE A VISIT? Patient payment is affected Medicare considers OVER CODING as a violation of the fraud and abuse regulations because of the additional reimbursement Medicare considers UNDER CODING as a violation of the fraud and abuse regulations because it encourages patients to overuse the clinic

5. CPT Procedure Codes All Procedure Codes that are normally performed in a physician’s clinic are applicable in the RHC If your coder is also your biller, the knowledge of what service to bill to which payer is imperative Some CPT codes will have to be “split” billed

6. Accurate Coding Better documentation does not mean MORE documentation checklists are not always a good practice just because a system is checked it doesn’t mean it was examined if it isn’t documented, it didn’t happen if audited, the record must stand alone; many times work is done, but no documentation Providers tend to undercode their cognitive services Levels coded accurately = correct reimbursement

7. Improving Coding Accuracy Note Review of Systems List patient complaints and concerns Document history taken Describe exam accomplished Note any injection to be given and nurse giving List and number diagnoses pertinent to visit Review lab findings Note prescriptions or samples given and/or requested tests List plan and follow-up

8. E & M Coding Definitions: New Patient Patient who has not had any professional services from that provider or any provider in the same specialty who are part of the same group practice within the past 3 years. If seen in the hospital and then in the clinic and if billed under a different tax ID number then the patient is considered new, if same tax ID number then established. Established Patient Patient who has received professional services from the provider or any other provider of the same specialty in the same group within the past 3 years.

9. E & M Coding Definitions: Consultation—Medicaredoes not recognize this code and code used should be changed to an OV E & M A service provided by a provider whose opinion or advice regarding a specific problem is requested by another provider. There must be a REQUEST (written or verbal, but documented in the chart), the consultation must be RENDERED and there is a written REPORT that must be given to the requesting provider. All are required to be in the patient chart. Even if in the same practice, there must be a report given. A consultation and a procedure can be coded separately on the same day with the modifier -25 on the consultation.

10. E & M Coding Definitions: Preventive CPT codes CPT codes for physical exams based on age Use when patient has no significant complaints or follow up of ailments Medicare does not pay for Preventive CPT codes Medicare will cover the Initial Preventive Physical Examination, paps, pelvic, Annual Wellness Visit, PSA, etc. (those listed in the Medicare beneficiary handbook) Medicare preventive services generally begin with “G”

11. E & M Coding Definitions: Time Used to determine E & M Level when counseling and/or coordination of care is more than 50% of the encounter Outpatient time is face-to-face time Inpatient time is unit/floor time Must document total time spent in minutes document what the counseling was about and/or what coordination of care was provided State “Counseling or Coordination of care greater than 50%” Counseling can be visiting about ailments, teaching, etc.

12. E & M Coding Definitions: Concurrent Care Similar services i.e. inpatient subsequent care, to the same patient by different providers of different specialties on the same day but must be for different problems. Example: Orthopedist seeing patient after knee surgery; family physician seeing patient in hospital for diabetes. As long as different ICD 9 Diagnosis codes, both are allowed when different specialty.

13. CPT E & M Coding Most Common used in RHC: Office Visits NF/SNF New Est. Initial Subseq. 99201 99211 99304 99307 99202 99212 99305 99308 99203 99213 99306 99309 99204 99214 99310 99205 99215 Many other E & M Codes, refer to CPT Coding manual

14. MODIFIER -25 Significant, separately identifiable E/M service by same provider on the same day of a procedure or other service. Append to E/M code , I.e. 99214-25 Use Modifier 25 when one of the following criteria is met: Visit for a problem unrelated to the procedure Visit for a new problem or a problem that has changed significantly and requires re-evaluation before performing the procedure. Visit for the same problem in different sites; one treated surgically and one treated medically.

15. MODIFIER -25 Visit for a problem unrelated to the procedure or service Preventive Care Visit = patient seen for annual physical E/M service = Patient also c/o leg pain, swelling and hot spot. Evaluated for phlebitis Supporting Documentation E/M documentation separate from procedure documentation Must meet ALL requirements for E/M visit along with documentation of procedure.

16. Medicare Part A Revenue Codes 521 Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, i.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All other revenue codes, i.e. 250 drugs, 270 supplies, are bundled with the visit code charges

17. MEDICARE INJECTIONS Injections with an Office Visit Add charges to the E/M code when submitting claim Code all services in Practice Management system Injections only—nurse service Charge out all services with correct CPT codes Either DO NOT bill as there is no face-to-face visit OR if it was in the plan of treatment at the last visit, add charges to that visit and submit total charges with the face-to-face visit date for payment (after all services performed) If injectable is a Part D drug it MUST not be a part of the RHC claim as it is only billable to the patient or to Part D

18. PART D - INJECTIONS Injectable/Vaccine as a Part D drug – 1/1/08 The injectable/vaccine is payable only through Pt D If injectable/vaccine is obtained at the clinic level, then the patient is to pay for the injectable/vaccine and the administration privately and then they have to submit that claim to their Part D company to be reimbursed for the services. Clinics can link to: www.mytrnsactrx.com (used to be eDispense) and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount.

19. Laboratory Services All coded with the accurate CPT code Don’t forget to charge the venepuncture CPT 36415 If more than one of the same test is done on the same day, a -91 modifier is added to the CPT code All Labs, to include the required basic 6 tests, are payable through Medicare Part B OR If PBRHC, they are payable through the Hospital OP provider number. No more than one 851 TOB can be submitted each day

20. Radiology Services All coded with the accurate CPT code for each the technical component and the professional component if provider interprets Chest x-ray = 71020-TC Two views frontal & lateral; 71020-26 x-ray interpretation Interpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Technical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number

21. EKG Services Coded using the tracing only for the TC & the interpretation only if provider does the interpretation. EKG Tracing only = 93005 EKG Interpretation and report = 93010 Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Tracing only is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number

22. “Incident to” Services Bundled with a face-to-face encounter within a 30- day period Direct supervision by provider required Must be in clinic, not in same room being in the hospital when attached to clinic is NOT incident to Part of provider’s services previously ordered integral, though incidental covered as part of an otherwise billable encounter i.e. dressing change, injection, suture removal, blood pressure monitoring Medicare (Medicaid if State requires) services should be billed under the provider that performed the service

23. “Incident to” Services When added to the f-t-f visit, the additional reimbursement is the 20% copay for the additional charges Otherwise, if not on a claim, all costs are part of your cost report and are included in your rate If the clinic costs are above the capped rate, the clinic will not get any additional dollars for these services through their cost report.

24. Hospital Procedures No global charges for Medicare in the RHC Each visit in the clinic is a billable visit Code the surgical procedure with -54 (surgical procedure only) and bill to Part B Bill the pre and post visits as RHC visits as it is the RHC facility billing the services, not a specific provider Any procedure in the Hospital should be the procedure only, not the aftercare involved

25. More Than One Visit Per Day Assure documentation as to why the second visit and time seen i.e. patient seen in a.m. for X and presents again at XX p.m. due to X Only allowed if a different illness or injury or a different medical specialty. If same diagnosis, accumulate to set E & M level If seen in clinic and then admitted Bill hospital admission

26. Flu & Pneumonia Injections Keep a log of injections, or have your computer track Medicare paid on your Medicare Cost Report Flu payable once per season; pneumo once lifetime Medicaid is paid only if in your State benefits at the time of service Keep track of vaccine and supply costs Determine average nursing hours per week Determine average provider hours per week Generally allow 10 minutes per injection on Cost Report, but do a time study Must verify that there are NO Medicare Advantage on log LOGS MUST BE LEGIBLE

31. Behavioral Health Services Clinical Psychologist (PhD) Clinical Social Worker (CSW) Use 900 revenue code to bill therapeutic behavioral health The first visit to determine services by a physician/PA/NP is an RHC visit, then behavioral health services apply

33. Preventive Services Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04 Technical Components, labs, EKG tracing are billed on the non-RHC side, either through the Hospital OP provider number (PBRHC) or to Medicare Pt B (IRHC) Examples to follow later

37. Annual Physicals Preventive physical Medicare: Does not pay for physicals, except for the Introduction to Medicare Physical. If the visit is only for a physical and not for the ailments, then bill the patient. Effective 1/1/11, Medicare will pay for an “annual wellness” visit per year; This IS NOT a physical Medicaid: Covered for kids and billed as an RHC Visit with the T1015 code w/U6 mod. Private/Commercial: Bill as in FFS clinic

50. Preventive Service Charges on Cost Report Charges for Preventive Services NOTE: Section 4104 of ACA eliminates co-insurance and deductible for preventive services, effective for dates of service on or after January 1, 2011. RHCs and FQHCs must provide detailed healthcare common procedure coding system (HCPCS) coding for preventive services to ensure coinsurance and deductible are not applied. Providers will need to maintain this documentation in order to apply the appropriate reductions on lines 16.03 and 16.04. (per instructions for Form CMS-2552-10 dated August 2011)