billing and coding- how to get paid!!!
TRANSCRIPT
Documentation
– The biggest part of billing and coding is DOCUMENTATION! If you didn’t document it, it didn’t happen.
– You are probably doing all the work of higher level coding, so why not document it and actually get paid for it?
Why Should You Care?
– It may seem overwhelming, but if you just take a little time to learn it, once you learn it, you’ve got it.
– More $ for your employer = more $ for you.
– Profit sharing, renegotiate contract after 6 months/1 yr.
– FRAUD
False Claims Act
– In addition to refunding payments and costs to the Federal
government for civil action:
– Treble damages –up to 3x amount violator received
– Civil monetary- up to $23,331 per false claim
– Additional fines and/or imprisonment
– Exclusion from Medicare, Medicaid, and all other Federal
healthcare programs => unemployable
Fraud Numbers:4 BILLION Recovered FY2019
FY 2020
624
Criminal actions
791
civil actions
2,148
Excluded from
participation
Terminology:
E/M codes: evaluation and management documentation
E/M => level of care your labor => $ reimbursement
CPT codes: Current Procedural Terminology; The five-digit CPT
coding system describes more than 8,000 medical diagnostic and
surgical services and procedures that are delivered to patients;
used to charge for services; developed by the American
Medical Association; (level of charge)
ICD: International Classification of Diseases; developed by the
World Health Organization; (Dx)
NPI: National Provider Identifier; your 10 digit unique # that
follows you throughout your career
Terminology cont..
– CMS: Centers for Medicare and Medicaid Services; PAs
register through PECOS, paid at 85%, “rendering provider”
through Medicaid
– Incident to: Billing under the physician’s NPI rather than the
PA in order to capture 100% billing from Medicare instead
of 85% in the CLINIC setting -many caviots…
– Split Share: Billing under the physician’s NPI rather than the
PA in order to capture 100% billing from Medicare instead
of 85 in the HOSPITAL setting –many caviots..
Direct Payment
– Direct billing: PAs are the only health professionals who are
authorized to bill Medicare for their services but are not
able to receive direct payment. BILL PASSED!! Jan. 2022
PAs WILL receive direct payment from Medicare!
– Direct payment by private insurers in Oklahoma passed in
2020 per SB1915 as well as all orders and reimbursement
recognized for PAs for anything as a physician AND PCP
status for PAs
Making It Easy
– Quick text or checkboxes
– Some parts the nurse can fill out for you
– Pocket card- MAKE SURE IT’S 2021!
– There’s an app for that:
– Document and Coding by Logica Med Solutions, Inc (free)
– ICD 10 Free or Pro
– Scribd
Recent Changes
– ICD-10 (changed from about 14,000 dx to about 69,000) in 2015
– E/M guidelines from 1995 and 1997
– Hospice – 2019
– Student notes are billable! Preceptor just has to sign and date after review – Jan 2020
– CMS is deferring to state law on how PAs practice with physicians –Jan 2020 Moving away from the term “supervision” and preferring the term “collaborate”; Okla changed to “delegate” in 2020
– Telemedicine and home health referrals laws 2020 and 2021
– Reimbursement changes in Oklahoma law 2020
– BIG changes to coding Jan 2021
GIANT Changes to Billing and
Coding in 2021
No longer using history or physical exam as criteria
Now code based on medical decision making
OR code based on time
What is Medical Decision
Making??
– Problems Addressed:
The number of problems you addressed for the patient during the
day of the encounter
Items Reviewed:
The tests, chart information, and other data you reviewed in
relation to the problems addressed that day
Risk:
The level of risk presented to the patient. (risk of the conditions to
the pt)
History
– Chief complaint-nurse can fill this out
– History of present illness (HPI)
– Review of systems (ROS)
– Past/family/social history (PFSH)
History-HPI
– Location- Where does it hurt?– Quality- Better or worse?– Severity-How bad is it?– Duration-When did it start? How long?
– Timing-When does it occur? Is it worse at certain times?
– Context-How did it happen?– Modifying factors-What has been tried to alleviate the
problem?– Associated signs and symptoms-Secondary symptom
associated with chief complaint
History-PFSH
– “Please refer to health history form for complete ROS and PFSH” or checkbox for health hx form reviewed and date
– Remember, documenting current meds is always a good idea, and it gets you a point here
– Meds, past surgeries, smoking, alcohol use, etc. all part of continuous chart…review and date
Assisting in Surgery
– Physician must be present during all critical or key portions
of the procedure and be immediately available during the
entire procedure
– Critical portions of 2 surgeries performed by the same
physician may not take place at the same time
– Social Securities Act will not allow Medicare to reimburse
for first asst fees for PAs at teaching hospitals if a resident is
available
Global Fee
– Insurance pays one fee to cover all visits associated with a
procedure so you don’t charge for each visit-even if
different providers see the patient on different visits
– CPT code 99024
– Postoperative follow-up visit, normally included in the surgical
package
– No fee, no RVUs
– Captures services normally included in the surgical package so you
can keep track of your provided services/value
Critical Care Services
3 Criteria:
Critically ill
High complexity decision making
Time
•One or more vital organ impaired
•High probability of life-threatening deterioration
•Care must be provided at the beside or on the floor/unit
•Must spend at least 30 minutes caring for patient
Critical Care Services
– After first 30 minutes of critical care time
– Any additional care time is counted
– Time spent may be either continuous or intermittent and then
totaled
– Must document total time that critical care services were
provided
Codes for critical care time:
99291: 30-74 minutes on a given day
99292: each additional 30 minutes of critical care time that day
Telehealth
– List of CPT codes for Telehealth:
https://www.cms.gov/Medicare/Medicare-General-
Information/Telehealth/Telehealth-Codes
– May also use modifier 95 on 99201-99205 and/or 99211-
99215 for audio-visual telehealth visits
Is 85% really less?
Hypothetical day in an ED Physician PA
Revenue with physician and PA providing the same 99283 service
$1650($66 x 25 visits)
$1400($56 x 25 visits)85% of $66=$56
Wages per day $1440($120/hr x 12 hours)
$636($53/hr x 12 hours)
“Contribution margin”(revenue minus wages)
$210 $764
Provider Type
Median Annual Compensation
Hourly Salary
Initial Hospital Care99221
Reimbursement
Initial Hospital Care 99221
Contri-butionMargin
Initial Hospital Care99222
Reimbursement
Initial Hospital Care 99222
Contribu-tionMargin
Initial Hospital Care99223
Reimbursement
Initial Hospital Care 99223
Contribu-tionMargin
Physician $250,000 $120 $103 -$17 $139 +19 +205 $85
PA $110,000 $53 $88 +$35 $118 +65 $174 $121
Difference $15 $21 $31
Know Your Value
Increase revenue
Decrease healthcare costs
Improve access to care and patient
throughput
Increase patient and staff
satisfaction
Contribute to process/quality
improvement and outcomes
Facilitate care coordination and communication
Final Thoughts
– Remember, both under-billing and over-billing are wrong
and can get you into trouble, so know what you are doing,
and please, please DOCUMENT!
– Global billing, no insurance, other pitfalls
– Questions?