Transplant Symposium: Hot Topics in Coding and Billing

1. Transplant Symposium: Hot Topics in Coding and Billing Julie Appleton, CCS-P, CPC, CPC-H, FCS, PCS

2. Disclaimer The materials utilized in this presentation are intended solely for use in conjunction with today’s seminar. Although great efforts have been taken in the preparation of today’s material, the speakers, nor their employers assume responsibility for errors or omissions or for damages resulting from the use of the information contained therein. Advice is general, thus participants should consult professional counsel for specific legal, ethical, technical and clinical questions prior to claim submission. This lecture was prepared with information that was publicly available at this time. Please consult official guidance prior to code preparation or submission.

3. Objectives • Shared Visits between NP’s and MD’s • Copy/Paste in the EMR • Provide information and planning for the impending transition of ICD-9-CM to ICD-10-CM on October 1, 2014.

4. Shared Visits

5. Incident to • What is incident to? • Physician establishes clear plan of care • Plan of care must be reason for visit • Plan of care should include the NP following patient • If Nurse Practitioner addresses new problem, visit should be billed under NP’s provider number • MD must see patient for new problem and modify plan of care to continue incident to billing

6. Incident to • Direct supervision • Must also meet requirements for direct supervision • Doctor must be readily available in the office suite area • If doctor is not available, service cannot be billed incident to. • Incident to and direct supervision requirements met • Billable in the MD’s name ***NP has to be credentialed to bill the services and meet all state and federal guidelines to report incident to.

7. Other things to consider • Clinic setting • Incident to does not apply in hospital based clinics • Know your setting when determining the appropriate way to bill for NP services.

8. Shared Visit Defined • A shared visit is a service shared by an MD and NP. • Both practitioners must perform a face to face visit with the patient. • Both must document his/her part of the service. • New patient visits cannot be billed as a shared visit. • Critical care services cannot be billed as a shared visit.

9. Shared Visits Clinic SettingProfessional Fee • Non facility based Clinic E/M • If incident to requirements are met, bill E/M in the name of the supervising physician. • If incident to requirements are not met, bill in the name of the NP. • Facility based clinic E/M - both practitioners can see the patient and document the portion of the service he/she performed. • Service can be billed in either practitioners name • Combine notes to determine level of service • Exceptions • New patient Visits ***Both providers have provider numbers!!

10. Shared Visits Hospital SettingInpatient/Emergency Department • Hospital E/M Service • Both practitioners can see the patient and document the portion of the service he/she performed. • Service can be billed in either practitioners name • Combine notes to determine level of service • Exceptions • Critical Care services ***Both providers have provider numbers!!

11. Shared Visit Documentation • How much does the MD and NP have to document? • Documentation must support that each practitioner had a face to face encounter with the patient. • Participated in the management of the patient. • Simple indication of review is not enough. • No face to face encounter by physician then the service must be billed in the NP’s name. • Notes can be combined to support the service billed.

12. Billing for Shared Visits

13. Non-Medicare Guidelines • Some other payers allow for billing in the name of the supervising MD if their system cannot handle billing by NPs, but they have agreed to the arrangement. • Know who those payers are!!

14. Copy/Paste in the EMR

15. Copy/Paste • Copy/ Paste Functionality • Copying of information from one medical record to another • Push button functionality in most systems • Ability to copy/ paste all or portions of a previous note • Systems don’t require editing • Lack of guidance and controls for this functionality by payers forces industry to fend for itself to define • Other Names for this Functionality • Cut/ Paste, Copy Forward, Carry Forward

16. Compliance Quandary • No agreed upon definition of what makes a quality note • Is the note accurate, concise, or written in a way another provider could pick up care and follow the patient? • No industry agreed upon definition of a cloned note • How can a compliance office judge whether a note is cloned or does not meet quality criteria?

17. Copy/Paste Function • Copy/Paste Function • Benefits • Efficient – extremely easy for provider to press a button to carry forward the previous note for a patient • Practical application for inpatient setting where patients condition does not drastically change from day to day • Practical application for specialized settings where a provider is treating a specific population of patients with the same condition

18. Copy/Pastse Function • Copy/Paste Function • Risks • Dangerous if controls are not in place to monitor use of this functionality • Provider not editing documentation appropriately • Increased risk of contradictions • Carrying forward the same error from visit to visit • Patient negative for disease but also positive for disease • Changes in patients condition • Redundancy of documentation from encounter to encounter • Increased risk of abuse

19. Carry Forward Policy Summary • Definition of Carry Forward • The process of using previously documented text from notes, reports, or other electronic sources to document a current patient encounter. This encompasses a variety of processes including, but not limited to, copy/paste; reuse; and auto-population functions, excluding dynamic data elements.

20. Create a Copy/Paste Policy • Key Points • Copy/Paste with caution. • Information that is copy/pasted is uniquely identified • More documentation does not necessarily mean better documentation

21. Copy/Paste Policy Essence • Do not document what you do not do! • Information created with copy/paste must be appropriately edited to accurately describe the patient’s condition and the services performed during the current encounter • If you sign it, you own it! • The signer of each entry is responsible for all of the content of his or her documentation, whether the content is original, created using copy/paste, or includes dynamic data elements • Supervising providers are responsible for verifying the accuracy of content documented by their designee (Resident, Fellow, etc.)

22. We have a problem? • How much editing makes it an edited note? • What is a quality note? • How do we know?

23. First Coast • First Coast Definition • Cloning of Medical Notes Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

24. Cahaba GBA • What is Cahaba's stance on cloning of medical documentation and what constitutes appropriate editing of a note that has been copied pasted into a medical record? • The medical necessity of services performed must be documented in the medical record and Cahaba would expect to see documentation that supports the medical necessity of the service and any changes and or differences in the documentation of the History of Present Illness, Review of System and Physical Examination. (August 2009)

25. Definition Please… • Where do we go next? • OIG Work Plan • 2011 OIG Workplan says the OIG will start to look at records with “identical documentation”. • 2012 OIG Workplan says the study regarding “identical documentation” will be complete in 2013. • Identical documentation • What will the definition be? • Clinical implications?

26. ICD-10 Overview

27. Introduction to THIMA • The Tennessee Health Information Management Association (THIMA) is an organization of health information management professionals that fosters the professional development of its members through education, representation, and lifelong learning. • THIMA is part of the American Health Information Management Association, one of the official ICD-10 Cooperating Parties responsibile for maintaining this official HIPAA-compliant transaction set. • These commitments promote quality health information for the benefit of the public, healthcare consumers, providers, and other users of clinical data. Learn more at: http://www.thima.org

28. ICD-10 Implementation • October 1, 2014 – Compliance date for implementation of ICD-10-CM and ICD-10-PCS • Another delay?

29. What is Changing? • ICD-10-CM • Diagnosis code sets • Impacts all settings including physician practices • ICD-10-PCS • Procedure coding • Impacts inpatient facility

30. Why The Need For Change ? • Lacks sufficient specificity and detail • It is 29 years old and becoming obsolete – no longer reflects the modern practice of medicine • Running out of space for new codes – it cannot accommodate advancements in medicine and medical technology • Cannot support the US transition to an interoperable health data exchange • Greater coding accuracy and specificity • Higher quality information for measuring healthcare service quality , safety, and efficiency • Aligns the United States with coding systems worldwide • Provides for recognition in advances in medicine and technology • Has the space to accommodate future expansion ICD-9 CM ICD- 10 CM/PCS The United States will be the only country to use ICD-10 data for reimbursement.

31. ICD-10-CM/PCS Final Regulation Physician ICD-10-CM Behavioral Health ICD-10-CM CPT / HCPCS CPT / HCPCS Hospital ICD-10-CM ICD-10-PCS inpatient Laboratory ICD-10-CM ICD-10-CM ICD-10-CM All Other CPT / HCPCS outpatient CPT / HCPCS CPT / HCPCS Long Term Healthcare ICD-10-CM ICD-10 AHIMA CPT / HPCPS

32. Departments Impacted

33. There are More Codes and More Details

34. Code Structure Differences ICD-9 Example

35. Code Structure Differences ICD-10 Example

36. ICD-10-PCS - Structure Characters (Med/Surg) 1 2 3 4 5 6 7 Root Operation Qualifier Section Approach Body System Body Part Device Surgeons will have to be educated to be more descriptive of the anatomy and procedures they are performing. ICD-10 AHIMA

37. ICD-9-CM Procedure versus ICD-10-PCS hfma Healthcare financial management association

38. ICD-9-CM Suture of Artery: One code (39.31) ICD-10-PCS Repair of Artery: 183 codes ICD-10 AHIMA

39. ICD-9 Comparison to ICD-10 • While hospitalized, a patient has a procedure done through an [endoscope] inserted [through the skin] to [bypass] the blood flow from the [abdominal aorta] to the [right] [renalartery] using a [synthetic material] ICD-9 Code Description 39.24Aorta-renal Bypass ICD-10 Code Description 04104J3Bypass Abdominal Aorta to Right Renal Artery with Synthetic Substitute, Percutaneous Endoscopic Approach

40. Logistical Issues in the transition from ICD-9 to ICD-10

41. ICD-10 Code Freeze • October 1, 2011 - last regular annual updates to ICD-9-CM and ICD-10-CM will be made. • After this date, code updates will be limited only to new diseases and technologies. • The ICD-10 Coordination and Maintenance Committee will continue to meet biannually. • On October 1, 2013, there are minimal ICD-9-CM changes due to the delay. .

42. Strategies for ICD-10 Communication and Collaboration must include at a minimum the following key people at your physician practices: • Finance - Contracting • Information Technology (IT) • Coding/Billing • Providers

43. Finance Cash flow reserves • Transition will create coding and claims processing delays • Enough reserves to keep organization afloat financially • Prepare for any unexpected costs • Potential reduced revenue due to delayed reimbursement

44. Organizational Self-Assessment • Contracting – Physician Profiling • Information Systems • Documentation • Encounter Form • Medical record - EMR • Current provider and staff knowledge gaps and opportunities AHIMA has a free assessment tool available at the following website http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046380.xls

45. Contracting – Physician Profiling • Absolutely crucial to know how ICD-10-CM diagnoses will affect medical necessity and fee schedules • What codes support medical necessity for the services rendered? • The mapping of ICD-9-CM to ICD-10-CM is NOT perfect. • Medicare has not yet published NCDs with ICD-10-CM codes yet • Stay tuned • Wouldn’t hurt to learn more about provider profiling • Medicare Value-Based Purchasing https://www.cms.gov/physicianfeedbackprogram/ • Check with BCBST and United Healthcare about their programs • If your IPA or group has a strategy to implement an Accountable Care Organization, consider how ICD-10-CM will affect the risk-adjustment methodology.

46. Information Systems

47. Information Systems • How are ICD-9 CM codes currently used in information systems? • Which vendor software applications are being used? • Can the system handle alphanumeric structure? • Can the current system house both ICD-9 and ICD-10 codes simultaneously?

48. Information Systems - Inventory • Create list of all systems using ICD-9-CM • Create vendor readiness assessment list • Use list to contact all vendors • Keep data base showing what you need to do for each vendor • Assign staff member to each vendor to follow through with I-10 readiness for this vendor • Target date for completing initial readiness assessment

49. Documentation Infrastructure • Inventory all forms that use ICD-9 diagnosis codes. • Encounter Forms may become quite lengthy • May require innovative (or computerized) approaches, especially with laterality and episodes of care. • Assess whether documentation currently in your medical records will support the level of specificity for ICD-10. • Ascertain that coding is based on provider documentation, not just what’s on the Encounter Form • Ascertain congruence between the codes indicated on the Encounter Form and what’s documented in the medical record.

50. Documentation Infrastructure • Download top codes you use now and crosswalk to ICD-10 • Help determine if continuation of paper form is possible (most likely not) • Give you an idea of key areas impacted by ICD-10 change for your specialty