best practices: physician billing/coding for hospice ... › handouts › hen › 1231... ·...
TRANSCRIPT
Best Practices:Physician Billing/Coding for Hospice & Palliative Care
Presented by:
Christopher P. Acevedo, CHC, CPC
Objectives
• Describe the circumstances that allow physician visits to be separately billable
• List common pitfalls made by providers in hospice and palliative care
• Differentiate the hospice benefit from billable physician services
• Discuss how to substantiate the medical necessity of physician visits through thorough documentation
You may pause now to download the handouts
Billable Physician Visits
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
What Physician ServicesAre NOT/Are Billable?
• Are NOT:– Medical director
• General supervisory services– Physician member of IDG (team physician)
• Participation is establishing or revising plan of care• Supervision of care and services• Establishment of governing policies
CFR 418.304 (a)
– Visits to Hospice patients performed by a Nurse Practitioner (NP), if the specific NP has not been formally elected as the Hospice Attending
© ACI 2009
E/M Services
• Billable encounters/visits– Medically necessary– Face-to-face
• Code sets by type of service and/or place of service– New patient vs. established patient
• Home visits• ALF, domiciliary, rest home visits
– Initial care vs. subsequent care• Inpatient hospital• SNF/NF
© ACI 2009
“Medically Necessary” Defined*
• MEDICALLY NECESSARY“Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.”
http://www.medicare.gov/Glossary/search.asp?SelectAlphabet=M&Language=English
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
CMS’ FAQ
• Q: For hospice services, why are rounds not considered a patient care visit?
• A: Rounds are an administrative activity rather than a patient careactivity. A visit provided during rounds would not be considered a patient care visit unless a patient required a physician’s assessment and/or intervention during the visit. Rounds performed in a facility for the purposes of writing orders or any other non-patient care required services, do not count as visits. (Revised) Reference:
http://www.cms.hhs.gov/transmittals/downloads/R1494CP.pdf
© ACI 2009
Medical Necessity
© ACI 2009
• Reason for visit – May/May Not Mirror Subjective Complaint– May/May Not be Related to Terminal Dx– May/May Not be Related to Level of Care
Medical Necessity
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Reason for Today’s Visit
© ACI 2009
Medical Necessity
© ACI 2009
Medical Necessity & E/M
• Documentation software may facilitate carry-overs and repetitive fill-ins of stored information.
• Even when a “complete” note is generated, only medically necessary services for condition of patient at time of encounter as documented can be considered when selecting appropriate level of E/M service.
• Information not pertinent to patient’s condition at time of encounter cannot be counted.
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Medical Necessity & E/M, cont.
• However, providers are entitled to appropriate level of reimbursement for medically necessary services that are supported by documentation.
• Should not down code or code “middle of the road”when a higher level of service has been rendered.
• Remember: down coding is as much of a billing error as up coding!
© ACI 2009
E/M Services
• Once the right “type” is identified– Location of the patient– New vs. Established– Initial vs. Subsequent
• Must choose right “level” of service– 3, 4 or 5 levels;– Based on documentation of history, exam,
and medical decision making; or– Time and counseling/coordination of care
Pitfalls
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Common Pitfalls –Documentation
• An Incomplete Hx Can Easily Sabotage an Encounter – Example:
• Upon admission to your IPU, a medically necessary physician visit takes place and an H&P is documented. The physician bills 99223. The documentation consists of a comprehensive Physical Exam and MDM is high, however the Hx lacks a documented Social Hx & Family Hx. How does this effect what should be billed?
© ACI 2009
Common Pitfalls –Documentation
• Even a 99221 requires these be documented…
• With the minimum documentation requirements not met for even a 99221, all that’s left is 99499: an unlisted E/M service.– Good luck getting paid!
© ACI 2009
Common Pitfalls –Documentation
• An Incomplete PE Can Also Easily Sabotage an Encounter – Example:
• A medically necessary MD visit takes place in a patient’s home. The physician bills 99345. The documentation consists of a comprehensive Hx and MDM is high, however the documented PE only consists of 7 OS. How does this effect what should be billed?
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Common Pitfalls –Documentation
• With both a 99344 & 99345 requiring a comprehensive PE, the highest level new-pt. home visit supported by the documentation is 99343.
© ACI 2009
Common Pitfalls –Type of Patient
• Established patient billed as New patients– Common occurrence as a pt may be
“new to me”
© ACI 2009
Common Pitfalls –Respite
• The million dollar question…
Would I be seeing this patient if they were not under our care for Respite?
If yes, it becomes even more essential to document a clear reason for TODAY’s visit.
© ACI 2009
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Common Pitfalls –Assumptions
• Most Common Pitfall!– Physicians Know How to Document
• “They run their own private practice, they must know how to do it…”
• Documentation from a coding/documentation compliance perspective is not inherent to Physicians!
© ACI 2009
WHO IS LOOKING AT US?
XYZ Hospice
The Fight Against Fraud & Abuse
• CMS– MACs
• Probe Audits– Prepayment Review– Statistical Valid Random Sampling (SVRS)
– ZPICs• Formerly Program Safeguard Contractors (PSCs)
– Recovery Audit Contractors (RACs)– Comprehensive Error Rate Testing (CERT) contractor– Medicaid Integrity Program (MIP)
• Don’t forget the Private Payers!– Special Investigative Units (SIU)– Contracted audit companies
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
2010 OIG Work Plan
PHYSICIAN BILLING FOR Medicare HOSPICE BENEFICIARIES
We will review the extent of Part B billing for physician services provided to Medicare hospice beneficiaries. Physicians may receive reimbursement for hospice services under Medicare Part Aor Part B. This study is a follow-up to recent OIG studies on hospice care. We will determine the frequency of and total expenditures for physician services under Part A and Part B for hospice beneficiaries. We will identify whether physicians double-billed hospice services to Part A and Part B.
2010 OIG Work Plan
TRENDS IN Medicare HOSPICE UTLIZATION
When the hospice benefit was created in 1982, Medicare did not cover more than 210 days of hospice care per beneficiary. Congress changed the benefit to eliminate the limit on the number of days covered by Medicare. Since then, the number and types of diagnoses associated with hospice utilization have increased and longer stays have become more common. We will examine the characteristics of hospice beneficiaries, geographical variations in utilization, and differences between for-profit and not-for-profit providers.OEI 00-00-00000; expected issue date: FY 2011; new start
Some Numbers
• 2006 Presidential Review – Hospice Services– Trends from FY 1995 – FY 2005
• Most dramatic annual increases between 21% to 26% occurred from FY ‘01 – ’05
• The greatest increases by provider:– Freestanding hospices – 28% in FY ’01 and 31% in FY ‘03 and ’04– Skilled nursing facility (SNF) based hospices – 25% in FY ‘03
• The greatest increases by care type:– Physician services - exceeded all other care types – 43% in FY ‘02 and
30% in FY ‘03– Continuous home care (CHC) – 33% FY ‘03 and 31% in FY ’04
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Cause for Concern?
• The average length of stay:– Continues to rise
• National average of 64 days in FY ’05 vs. 53 in FY ’02• Freestanding facilities - 69 days in FY ’05 vs. 57 in FY ’02
• Expenditures continue to rise at double digits each year– Number of beneficiaries/amount of outlay per beneficiary has
been increasing at a much more modest rate.
Staggering Numbers
• 491% increase in total outlays for freestanding hospices
• Outlays for physician services have risen 641%!
Decrease in Cancer Related Dx
Source CMS Hospice Data
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Some Additional Numbers
Source CMS Hospice Data
Internal Controls
© ACI 2009
Best Practices in Billing/Coding
• Identify the Internal Experts (you may be surprised)• Identify Physician Champions of Compliance
– Your Best Ally
• Education– For Providers (you will be surprised!)
• Include Appropriate Billing Staff– For Leadership Team
• Documentation is the Key– Provide Cheat Sheets (trying to teach new tricks!)
• QAPI• Consider Outside Audit
– Mock Payer Review
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Auditing/Monitoring
• What type of quality checks do you have in place?– Assessing physician/NPP documentation– Assessing contract physician documentation
• YOU are billing for these services? Are they being documented appropriately?
– Annual Code Changes• Changes to coding rules
– Annual Rule Changes• Are we in compliance today?
Compliance Guidance
• What codes do we look at? – a random sample of claims/services?– all claims/services from a particular payer?
• Identify risk areas– Use these risk areas as the universe of claims/services from
which to select the sample • OIG recommends an evaluation to determine if the
codes billed and reimbursed were accurately ordered, performed, and reasonable and necessary for the treatment of the patient
What are you looking for?
• Evaluation & Management– Consultation vs. Referral– Levels of E/M service
• Can you read it?• Can you tell who provided the service?• Can you tell in what setting service was provided?
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Compliance Guidance
• Must make appropriate response when problem identified– Timely
• Specific action depends on circumstances – May be straight forward
• repayment with appropriate explanation to payer– May need to involve a Qualified Health Care Attorney
• to determine the next best course of action
Post Audit Follow-Up
• Education– Physicians, NPPs, nurses– Staff (registration, coding/billing, administrative)
• Processes to prevent identified errors from reoccurring
• Monitoring techniques– Correspondence from the carriers and insurers challenging the medical
necessity or validity of claims – Check productivity reports for illogical patterns or unusual changes the
pattern of CPT, HCPCS or ICD.9 code utilization – Review monthly A/R reports for high volumes of unusual charge or
payment adjustment transactions.
Follow-up
• Focused review– Targeted area of coding, documentation– W/in 30-90 days of education– New physician, new service
• Progressive action– One CPT code on 100% prospective review– All coding on 100% prospective review
• Comparisons• Rewards!• Start all over again
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Auditing/Monitoring
• At what point do we hire a coder?• What credentials should he/she have?• Experience?• Where do we look?• How do we monitor the coder?
– How do we know what we don’t know???
Education Needs
• Recognize the importance of continued education
• Educate physicians/NPPs as new hires!• Regulations change frequently – have a
plan to keep up with changes• Develop templates that incorporate coding
requirements• Use billing/coding “Cheat sheets”
Assessing Providers
• Who are your outliers• What are the most frequent E/M codes• Keep track w/ benchmarks
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009
Education Needs –Provider Meetings
• Case studies• Selective review of random charts• Time allotted each quarter to billing/coding
teaching• Focus on basics
Agency Education Needs
• Assign someone to “own”• Knowledgeable about provider billing• Become familiar w/ nuances• Review transmittals from Medicare• Benchmark your provider billing/coding• CME yearly
© ACI 2009
Christopher P. Acevedo, CPC, CHCAcevedo Consulting Incorporated
561.278.9328Cacevedo@acevedoconsulting.comwww.AcevedoConsultingInc.com
Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care
Hospice Education Network (c) 2009