ehr pitfalls keep coders on their toes -...
TRANSCRIPT
Plus: E-prescribing • Moderate Sedation • Medicare Risk Adjustment • Ophthalmology • Payer Certification
EHR PitfallsKeep Coderson Their Toes
August 2009
Ronda Tews, CPC, CHC, CCP-PTed McMurry, M.D. Carolyn Combs, RN
Eiamee Kue, Patient
www.ASHIM.org
ASHIMAmerican Society of Health Information Managers
www.aapc.com August 2009 3
[contents] 5 Letter from the Director of Business
and Member Development
7 Letter from Member Leadership
8 Letters to the Editor
In Every Issue
12 Stabilize Your Accounts Receivable David Peters, CPC, CPC-P, PCS, CCP-P, provides tips for effective contract
negotiation in part two of this two-part series.
20 Validate Coding Data with CDIPs in Medicare Risk Adjustment Polish your coding knowledge and skills with the 2009 hot topic of clinical
documentation improvement plans (CDIPs). Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P, has the information you need.
26 EHR Pitfalls Keep Coders on Their Toes Ronda Tews, CPC, CHC, CCP-P, explains why coders and physicians are finding
electronic health records (EHRs) aren’t the magic bullet to singlehandedly reduce medical errors, promote standardization of care, reduce costs, and increase physician efficiency.
28 Exam Level Matters in Ophthalmology Knowing when to bill a medical exam versus a routine vision exam ensures proper
reimbursement, reports Jennifer Worthy, CPC, OCS.
32 The Driving Parts of E/M Level Selection In this final installment on level selection, Katherine Abel, CPC, CPC-I, CMRS,
focuses on the MDM component—perhaps the most important of the three pri-mary components of E/M code selection.
48 Reduce Risk of Poor Moderate Sedation Choices When differentiating moderate sedation services, Samantha Mullins, CPC, CPC-I, ASC-AN, MCS-P, considers who administers the anesthesia, and then she gets age and time specific when choosing codes.
On the Cover: St. John’s Health System’s Corporate Compliance Project Manager Ronda Tews, CPC, CHC, CCP-P, reviews Medical Director Dr. Ted McMurry’s EHR code choices while Carolyn Combs, RN, treats patient Eiamee Kue, in St. John’s Hospital emergency department, Springfield, Mo. Cover photo by AV and Media Production Manager Gina Stidham (www.stjohns.com/).
Education
People
Coming Up
contents
August 200936
10 Coding News
44 Extreme Coding
31 Test Yourself FAQ
38 Newly Credentialed Members
3220
Chiropractic Certification
Fetal Well Being
What Not to Do on Appeal
Swine Flu Codes
Overall E/M Level
Features
26
4 AAPC Coding Edge
AAPC Code of Ethics
Members of the American Academy of Professional Coders (AAPC) shall be dedicated to providing the highest standard of professional coding and billing services to employers, clients, and patients. Professional and personal behavior of AAPC members must be exemplary.
AAPC members shall maintain the highest standard zof personal and professional conduct. Members shall respect the rights of patients, clients, employers, and all other colleagues.Members shall use only legal and ethical means in all zprofessional dealings, and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive, or illegal acts.Members shall respect and adhere to the laws and regulations zof the land, and uphold the mission statement of the AAPC.Members shall pursue excellence through continuing zeducation in all areas applicable to their profession.Members shall strive to maintain and enhance the dignity, zstatus, competence, and standards of coding for profes-sional services.Members shall not exploit professional relationships with zpatients, employees, clients, or employers for personal gain.
This code of ethical standards for members of the AAPC strives to promote and maintain the highest standard of professional service and conduct among its members. Adherence to these standards assures public confidence in the integrity and service of professional coders who are members of the AAPC.
Failure to adhere to these standards, as determined by AAPC, will result in the loss of credentials and membership with the American Academy of Professional Coders.
Volume 20 Number 8 August 1, 2009Coding Edge (ISSN: 1941-5036) is published monthly by the American Academy of Professional Coders, 2480 South 3850 West, Suite B. Salt Lake City, Utah, 84120, for its paid members. Periodical postage
paid at the Salt Lake City mailing office and others. POSTMASTER: Send address changes to:
Coding Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City, UT, 84120.
CEO and PresidentReed E. Pew
Vice President of Clinical Coding ContentSheri Poe Bernard, CPC, CPC-H, CPC-P
Vice President of Strategic DevelopmentDeborah Grider,
CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CDERC, [email protected]
Vice President of MarketingBevan Erickson
Director of Business and Member DevelopmentRhonda Buckholtz, CPC, [email protected]
(814) 673-7177
Director of Coding CommunicationsJohn Verhovshek, MA, [email protected]
Director of Member ServicesDanielle Montgomery
Director of PublicationsBrad Ericson, MPC, CPC, COSC
Senior Editors Michelle A. Dick, BS Renee Dustman, BS [email protected] [email protected]
Production ArtistTina M. Smith, AAS Graphics
Display AdvertisingJamie Zayach, BS
[email protected] all inquires, contributions and
change of address notices to:
Coding EdgePO Box 704004
Salt Lake City, UT 84170(800) 626-CODE (2633)
© 2009 American Academy of Professional Coders, Coding Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from the AAPC is prohibited. Contributions are welcome. Coding Edge is a publication for members of the American Academy of Professional Coders. Statements of fact or opinion are the respon-sibility of the authors alone and do not represent an opinion of the AAPC, or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2008 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein.
CPC®, CPC-H®, CPC-P®, and CIRCC® are registered trademarks of the American Academy of Professional Coders.
Targeting the AAPC AudienceThe membership of AAPC, and subsequently the readership of Coding Edge, is quite varied. To ensure we are providing education to each segment of our audience, in every issue we will publish at least one article on each of three levels: apprentice, professional and expert. The articles will be identified with a small bar denoting knowledge level:
APPRENTICE
PROFESSIONAL
EXPERT
Beginning coding with common technologies, basic anatomy and physiology, and using standard code guidelines and regulations.
More sophisticated issues including code sequencing, modifier use, and new technologies.
Advanced anatomy and physiology, procedures and disorders for which codes or official rules do not exist, appeals, and payer specific variables.
Serving 79,000 Members – Including You
August 2009
www.aapc.com August 2009 5
Members often ask what the AAPC is doing to increase the awareness and value of the Certified Professional Coder (CPC®) creden-tial. The answer is: We are working behind the scenes with state medical societies and physician specialty organizations to build strong working relationships and to co-brand educational material.
Our goal is to help physicians understand the value of certified coders and expand the opportunities for our certified members within the medical community. Whether you’ve earned a core credential, a specialty credential, or multiple credentials, we understand the hard work and dedication you have put into becoming a certified member. By developing relationships with various physician organizations and medical societies, the AAPC brings awareness to the forefront, provides knowledge and assistance to physicians, and creates win/win situa-tions for our members and other organiza-tions. With these partner organizations, the AAPC shares educational opportunities (i.e., inviting their members to our workshops, offering speakers or articles for their events, etc.), as well as provides opportunities for our members to obtain discounts on both state and specialty organization functions.
Over the last nine months, the AAPC has contacted health care facilities across the country making sure they are aware of the value of utilizing CPCs® for their outpatient physician coding. To date, almost 6,000 calls have been made. This effort has also increased our participating Project Xtern facilities, which now exceeds 200 locations. I believe we will continue to see future positive results by expanding our facility relationships and stressing the importance of CPCs® to their outpatient coding.
While the progress we have made so far in developing relationships with specialty orga-nizations is promising, it does take time. I look forward to the continuing development. Our list of societies with whom we have working relationships grows each month. Here are some of the organizations with which we currently work:
American Academy of Pediatrics (AAP)
American Chiropractic Association (ACA)
American College of Rheumatology (ACR)
Association of Dermatology Administrators Managers (ADAM)
American Health Lawyers Association (AHLA)
Association of Otolaryngology Administrators (AOA)
ENT Resources, Inc. (ENTRI)
In addition to these listed specialties, many society members sat on our specialty exam steering committees, offering their input and expertise, while others reviewed our exams. We continue to work with state medical societies providing resources, arti-cles, and events for states such as Arkansas,
Washington, D.C., Michigan, Pennsylvania, and Texas. I am excited about the ongo-ing success of these relationships and look forward to building more in the coming months, creating a vast wealth of resources and opportunities for our members.
If you have a contact inside a specialty society or state medical society you feel could be help-ful to our organization, please feel free to con-tact me at [email protected].
letter from the director of business and member services
Strong Working Relationships Build Value
Sincerely,
Rhonda Buckholtz, CPC, CPC-I, CENTC, CGSC, COBGC, CPEDC
CPT® and RBRVS 2010 Annual SymposiumThe only three-day event where you hear and learn direct
from the source of CPT—the AMA! Let the coding and payment policy experts from the American Medical Association (AMA)
sharpen your skill set and help refine your reimbursement process.
Join hundreds of colleagues in meeting and learning from the foremost authorities on Current Procedural Terminology (CPT®), the Resource-Based Relative Value Scale (RBRVS) and Medicare payment policy.
This year’s symposium faculty features leading experts in the �eld of coding and payment policy, and include members of the CPT Advisory Committee, CPT Editorial Panel, Relative Value Scale Update Committee (RUC), the Centers for Medicare & Medicaid Services (CMS) and Contractor Medical Directors (CMD). Presenters will discuss in detail many of the signi�cant changes to CPT 2010 codes and descriptors, as well as 2010 payment policy and relative value unit (RVU) changes to the Medi-care physician payment schedule.
Included in the symposium registration fee are the following complimentary products valued at more than $300:
CPT® 2010 Professional Edition
CPT® Changes 2010: An Insider’s View
CMS Federal Register featuring revisions to payment policy and RVUs for 2010 and the Medicare payment schedule in an easy-to-use Microsoft® Excel �le
Spots fill up fast—register today! Discount rate: $750Full rate: $900Cost includes free CPT 2010 Professional Edition and CPT Changes 2010 books, continental breakfast, lunch and cocktail reception.
For more information, or to register today, visit www.ama-assn.org/go/symposia or contact the AMA at (800) 621-8335
“I’ve attended the CPT & RBRVS Symposium for over 10 years (since 1998) and wouldn’t miss the annual event! The information presented is essential to understanding the intent of CPT updates and foundational to successful coding.”
Charla Prillaman, CPC, CPC-I, CEMC, CCC, CHCO Director, Physician Compliance
Save the date!CPT® and RBRVS 2010 Annual Symposium
Join hundreds of your colleagues and meet and learn from the experts at this year’s symposium. Topics include Current Procedural Terminology (CPT®), the Resource-Based Relative Value Scale (RBRVS) and Medicare physician payment policy.
Visit www.ama-assn.org/go/cpt for updates and information about registration, hotel accommodations and more!
Symposium sells out.
www.aapc.com August 2009 7
The American Academy of Professional Coders’ (AAPC) Web site recently became a topic of interest for the National Advisory Board (NAB). One evening, during one of our discussions, we were all shocked at how little we knew about the programs and ser-vices offered on the AAPC Web site. Some board members said they felt inept on com-puters and others said they weren’t aware of the great services and savings the AAPC offered its members online. If our board thought this way, what must our member-ship think?
Fortunately for us, we had AAPC Vice President of Marketing (and Web site whiz) Bevan Erickson on the call and he addressed our concerns. We asked Bevan to walk us through some of the great services and sav-ings offered on the AAPC Web site; and we were amazed at what we learned.
On the AAPC Web site, you can:
z Communicate online 24/7. Visit the AAPC membership forums (www.aapc.com/mem-berarea/forums/index.php) to network, find employment, get answers to coding questions, or simply chat with fellow coders from around the globe;
z Save money. Your membership includes discounts on books, training courses, and audio conferences;
z Advance your training. Sign up for continuing education programs, certification programs, and webinars;
z Become enlightened. It’s easy to do with all the free education from magazines, forums, emails, and chapter meetings the AAPC offers;
z Stay informed. Register to attend the many conferences, workshops and regional meetings the AAPC offers.
Plus, members receive general savings at Target, Kmart, Barnes & Noble, Lane Bryant, and Office Depot. Go to www.aapc.com/MemberArea/benefits/index.aspx#savings for a complete list of stores participating in the AAPC Savings Con-nection. Members can also find discounts on cruises, restaurants, hotels, car rentals, movies, and more.
Keep checking the Web site for new ser-vices, industry leading news coverage, coding links, local chapter information, coding forum threads, and discounts, just to name a few.
With 79,000 members and counting, the AAPC influences the direction of the indus-try, ensuring its members receive the rec-ognition, appreciation, credibility, and pay they deserve. Our services, the recognition of certification, and local chapter member-ship give us value as members. With that in mind, the AAPC Web site should be a tool its members use daily.
letter from member leadership
AAPC Web Site:A Coding Tool Membership Can Rely On
Sincerely,
Terrance C. Leone, CPC, CPC-P, CPC-I, CIRCC
President, National Advisory Board
CPT® and RBRVS 2010 Annual SymposiumThe only three-day event where you hear and learn direct
from the source of CPT—the AMA! Let the coding and payment policy experts from the American Medical Association (AMA)
sharpen your skill set and help refine your reimbursement process.
Join hundreds of colleagues in meeting and learning from the foremost authorities on Current Procedural Terminology (CPT®), the Resource-Based Relative Value Scale (RBRVS) and Medicare payment policy.
This year’s symposium faculty features leading experts in the �eld of coding and payment policy, and include members of the CPT Advisory Committee, CPT Editorial Panel, Relative Value Scale Update Committee (RUC), the Centers for Medicare & Medicaid Services (CMS) and Contractor Medical Directors (CMD). Presenters will discuss in detail many of the signi�cant changes to CPT 2010 codes and descriptors, as well as 2010 payment policy and relative value unit (RVU) changes to the Medi-care physician payment schedule.
Included in the symposium registration fee are the following complimentary products valued at more than $300:
CPT® 2010 Professional Edition
CPT® Changes 2010: An Insider’s View
CMS Federal Register featuring revisions to payment policy and RVUs for 2010 and the Medicare payment schedule in an easy-to-use Microsoft® Excel �le
Spots fill up fast—register today! Discount rate: $750Full rate: $900Cost includes free CPT 2010 Professional Edition and CPT Changes 2010 books, continental breakfast, lunch and cocktail reception.
For more information, or to register today, visit www.ama-assn.org/go/symposia or contact the AMA at (800) 621-8335
“I’ve attended the CPT & RBRVS Symposium for over 10 years (since 1998) and wouldn’t miss the annual event! The information presented is essential to understanding the intent of CPT updates and foundational to successful coding.”
Charla Prillaman, CPC, CPC-I, CEMC, CCC, CHCO Director, Physician Compliance
Save the date!CPT® and RBRVS 2010 Annual Symposium
Join hundreds of your colleagues and meet and learn from the experts at this year’s symposium. Topics include Current Procedural Terminology (CPT®), the Resource-Based Relative Value Scale (RBRVS) and Medicare physician payment policy.
Visit www.ama-assn.org/go/cpt for updates and information about registration, hotel accommodations and more!
Symposium sells out.
8 AAPC Coding Edge
letters to the editor
History Element Drives E/M Level CorrectionIn the June 2009 article “The Driving Parts of E/M Level Selection,” the author states that a detailed history contains a brief history of present illness. This is incorrect. A detailed history contains an extended HPI.
In fact, a detailed history does require an extended HPI. The statement on page 33, “The second HPI level, an extended HPI, correlates to a comprehensive work level,” should have specified that the second HPI level, an extended HPI, cor-relates to either a detailed or comprehensive work level. The History Level Selection Chart on page 35 was incorrect, and should have stated that an extended HPI is required for a detailed overall history. A brief HPI is required for a problem focused or expanded problem focused overall history.
Alice Anne Andress, CCS-P, CCPChief Compliance Office at Albert Einstein Healthcare Network
The statement “The 1997 E/M documentation guidelines also allow credit in the HPI for patients who are seen for chronic conditions, such as if the patient states, ‘I am here today to follow up with my COPD,’” requires clarification.
It is not sufficient simply to document the chronic prob-lem. The status of at least three chronic (or inactive) condi-tions must be documented to meet the requirements of an extended HPI. Furthermore, this option is available only for an extended HPI. If the status of less than three chronic (or inactive) conditions is documented, without documentation of any of the eight HPI elements, the documentation guidelines for a brief HPI have not been satisfied.
Maryann C. Palmeter, CPC, CENTC Associate director of the Office of Physician Billing Compliance
University of Florida Jacksonville Healthcare, Inc.
Many thanks to Alice Anne and Maryann for catching the oversights. We received several other letters regarding this article. Another reader provided additional detail on whether you may “mix and match” 1995 and 1997 E/M documentation guidelines. She pointed to recently-updated FAQ (No. 2) posted on the Highmark Medicare Web site (www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#2), which states:
“The 1997 guidelines provided the specialty examination guidelines only. Therefore, the history and medical-decision making components from the 1995 guidelines are used for all evaluation and management services. This said, under the history component, the Status of chronic conditions was added after the 1995 guidelines were instituted. This element of the history component is also available for all services.”
That is, Highmark allows providers to count the status of chronic conditions as an element of the patient history, even when applying the 1995 documentation guidelines for the examination component. Coding Edge overlooked this important information for those provid-ers billing Highmark (and a few other payers), but coders will want to exercise caution before applying such a standard to all payers.
Most payers do not consider “status of chronic conditions” as appli-cable under the 1995 guidelines. For those payers, selecting the 1995 exam guidelines means also accepting the history guidelines as they appear in the original 1995 document—without the option to consider status of chronic condition as an element of HPI, as is allowed specifically in the 1997 guidelines. As such, you would not “mix and match” the history and exam elements of the 1995 and 1997 E/M guidelines. (The medical decision making requirements are, however, the same for both sets of guidelines.) When in doubt, check with your individual payer for specifics.
The same reader sought clarification on what constitutes “double dip-ping” between the history of present illness (HPI) and the review of symptoms (ROS). She again cites a FAQ (No. 14) posted on the High-mark Web site, which advises: “ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered ‘double dipping’ to use the system(s) addressed in the HPI for ROS credit.” The source of this information is given as the Medicare A/B Reference Manual (chapter 23, “Evaluation and Management,” section e.3).
The Medicare A/B Reference Manual (www.highmarkmedicareservices.com/refman/index.html) does not represent national Medicare policy, but is specific only to Highmark. More seriously, the material quoted in the FAQ and credited to the Medicare A/B Reference Manual actually does not appear in that document.
Despite the botched reference, the advice given in the Highmark FAQ has merit. Both the 1995 and 1997 E/M documentation guidelines are silent on “double dipping,” and national Medicare policy does not appear to address the issue of using one physician statement to count for two separate elements of history.
An article in the July 1999 Physician Practice Coder (ercoder.com/downloads/files/PPC_1999_DD_Clarification.pdf) suggests that the prohibition against using one item in both the ROS and HPI is based on misunderstood statements delivered at a conference in late 1997 by then-Health Care Financial Administration (HCFA) executive medi-cal officer Burt McCann.
McCann, in direct response to an inquiry, later clarified, “You ask if a single statement may be used in the history of present illness and still be counted in the review of systems without actually being writ-ten twice … it is not necessary to mention an area of history twice in order to meet the documentation requirements for the ROS.”
Despite McCann’s clarification, many payers instituted ROS/HPI double dipping rules based at least in part on McCann’s earlier, mis-understood statements. Neither the Centers for Medicare & Medicaid Services (CMS) nor the American Medical Association (AMA) has offered further guidance on the issue. Individual carrier directors have the power to interpret the documentation guidelines in their own way, and many still prohibit using one documented statement to count for two separate history elements.
Letters to the Editor
Please send your letters to the editor to: [email protected].
www.aapc.com August 2009 9
letters to the editor
Resource tip: You can read a full recounting of the double dipping “urban legend” on the ER Coder Web site at www.ercoder.com/discussion/topic.php?id=17 and on the Medical Newswire Web site at http://medicalnewswire.com/artman/publish/article_6570.shtml.
The issue of whether you may double dip between the ROS and HPI is more nuanced than Coding Edge initially recognized. Highmark and other payers may allow you to count a single element twice for the ROS and HPI, and the weight of logic may favor such accounting. A greater number of payers, however, do not allow you to count a single element twice for the ROS and HPI.
The best advice, once more, is to ask your individual payer for guid-ance, and get it in writing.
Coding Edge
Don’t Settle on Outdated ResourcesRegarding the letter to the editor “Payer Matters When Reporting Time-Based Critical Care Services,” in the June 2009 issue, which referenced the April 2009 article “Pediatric Critical Care Codes Moved for Easier Coding:” Susan Ste-vens, CPC, asked why a service lasting 80 minutes would be reported as 99466 Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or criti-cally injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport, only.
Although I agree with the Coding Edge editor’s answer, the supporting documentation and logic in the explanation aren’t entirely accurate.
The answer provided by Coding Edge cited an outdated resource (CR 5993, first released June 6, 2008), and provided logic in comparison to the critical care time guidelines cited in this resource:
“Critical care of less than 15 minutes beyond the first 74 min-utes or less than 15 minutes beyond the final 30 minutes is not separately payable.” This was revised in the July 9, 2008 rerelease of CR 5993 to read: “Critical care services less than 30 minutes total duration on a given calendar date shall be reported using an appropriate E/M code such as subsequent hospital care code and not a critical care code.”
Also, it is important to note that CR5993 was released for codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service), not 99466 and +99467 Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; each additional 30 min-utes (List separately in addition to code for primary service).
Although it is tempting to compare the CPT® instruction for Critical Care (99291-99292) with Pediatric Critical Care Patient Transport (99466-99467), the instructions for use of the “additional time” codes (+99292 and +99467) in CPT® differ. CPT® states, “Code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes” and, in contrast, “Code 99467 is used to report each additional 30 minutes provided on a given date.”
The American Academy of Pediatrics supports the more conservative approach to reporting 99467 in their “Coding for Pediatrics” manual, which states, “If the face to face time is less than 15 minutes beyond the initial 30 to 74 minutes, code 99467 is not reported.”
Therefore, 80 minutes of pediatric critical care transport would qualify as 99466 only.
Kelly C. Loya, CPC, CPC-I, CPhT
Thank you Kelly for confirming our answer and correcting our logic.
In following the American Academy of Pediatrics advice you cite, the time requirements for 99466 and +99467 are:
Documented Time Pediatric Critical Care Patient Transport Code(s)
Less than 30 minutes N/A
30-89 minutes 99466
90-119 minutes 99466, 99467
120-149 minutes 99466, 99467 x 2
And so on …
The updated version of CR5993 can be viewed on the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf. Among other changes, the revised CR provides new guidance on reporting critical care codes 99291-99292, which now matches CPT® instructions.
Coding Edge
June Correction:The article “Avoid Prolonged Services Pitfalls” (June 2009, p. 19) stated “For CPT® 2009, AMA revised the descriptors of inpatient critical care codes….” This should have read, “For CPT® 2009, AMA revised the descriptors of inpatient pro-longed attendance codes….”
10 AAPC Coding Edge
coding news
H1N1 Prompts Urgent ICD-9-CM Code ExpansionIn case you didn’t read our June EdgeBlast, new ICD-9-CM codes were created to provide data capture for the novel H1N1 influenza A virus (swine flu) after the March 2009 ICD-9-CM Coordination and Main-tenance Committee meeting and the World Health Organization (WHO) declared a global pandemic alert on June 11.
As part of the 2009 Addenda for ICD-9-CM, three-digit codes 487 and 488 have been expanded and revised. Do not use these codes until Oct. 1, 2009
487 Influenza Influenza caused by unspecified influenza virus Excludes: Hemophilus influenzae [H. influenzae]: influenza due to 2009 H1N1
[swine] influenza virus (488.1) influenza due to identified avian
influenza virus influenza due to identified novel
H1N1 influenza virus (488.1)
488 Influenza due to identified avian influ-enza viruses
Excludes: influenza caused by other unspecified influenza viruses (487.0-487.8)
488.0 Influenza due to identified avian influenza virus
Avian influenza Bird flu Influenza A/H5N1
488.1 Influenza due to identified novel H1N1 influenza virus
2009 H1N1 [swine] influenza virus Novel 2009 influenza H1N1 Novel H1N1 influenza Novel influenza A/H1N1 Swine flu
Highlights of the July 2009 Quarterly Update to OPPS
By Denise Williams, RN, CPC-HThe July update to Hospital Outpatient Prospective Payment System (OPPS) was
issued in Transmittals 107, 1739, 1760, MLN Matters articles MM6480, MM6477, MM6492, and includes version 10.2 of the Integrated Outpatient Code Editor (IOCE) and version 15.1 of the Correct Coding Ini-tiative (CCI) edits.
Updates to the Claims Processing Manual, pub. 100-04, chapter 4, section 10.7.2 fur-ther specify that the OPPS outlier recon-ciliation policy criteria uses OPPS-specific information, and is not based on informa-tion from the Inpatient Prospective Payment System (IPPS) or other payment systems.
The July update corrects programming errors from the January 2009 OPPS Pricer. These errors affect payment for certain blood products related to the blood deduct-ible. The blood deductible is applicable if a hospital purchases the blood product itself, in addition to processing and storage fees incurred by all hospitals. Specific details of the impact of this error are detailed in Transmittal 1745. Payment rates for four drug HCPCS Level II codes were incorrect in the January 2009 OPPS Pricer and are corrected with this update: J1441 Filgrastim; J1740 Ibandronate sodium; J2505 Pegfilgrastim, and; J7513 Daclizumab.
New HCPCS Level II codes are effective July 1: Nine codes are designated for pass-through status; two codes are designated as non pass-through, but are separately pay-able; and two had significant description changes, retroactive to 2008.
The Centers for Medicare & Medicaid Ser-vices (CMS) reiterates all HCPCS Level II codes for drugs, biological, and radiophar-maceuticals to be reported on claims, and reported units are to be based on the long descriptor for the individual code. This is not mandatory, but not reporting codes may negatively affect future ambulatory payment classification (APC) payment calculations. Updated payment rates for drugs and bio-
coding news
www.aapc.com August 2009 11
coding news
logicals that are paid based on average sales price (ASP) will be noted in the updated Addendum B for July.
CMS readdresses reporting instruc-tions concerning biologicals that can be implanted surgically or inserted. One example is a biological used as an alter-native to human or nonhuman connec-tive tissue. In this situation, the HCPCS Level II code for the biological should be reported only if the item has pass-through status. The charge for the item should be reported, but without the HCPCS Level II code as the OPPS payment methodol-ogy packages these items into the payment for the procedure. Another option in this scenario is to report the implanted bio-logical with an applicable device HCPCS Level II code, if available. For example, if a biological is used as a sling graft for uri-nary incontinence, it may be reported with C1771 Repair device, urinary, incontinence, with sling graft.
CMS also reiterates instructions concerning reporting code C9399 Unclassified drugs or biologicals. This code reports a new drug or biological recently approved by the FDA, but without a product-specific HCPCS Level II code assigned. Beginning on the date of FDA approval, hospitals may report the drug or biological with C9399. This code is used for a new chemotherapeutic agent or monoclonal antibody newly approved by the FDA.
CMS updated the manual language related to observation services. References to “admission” and “observation status” were removed for this outpatient service.
Updated procedure/device and radiophar-maceutical/nuclear medicine edits will be posted on CMS’ Web site along with updated Addendum A and B files at www.cms.hhs.gov/HospitalOutpatientPPS/.
advertising index
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12 AAPC Coding Edge
Payer/provider contracts can make or break a medical practice. Here are some tips for effective contract
negotiation.
Tip 1: Keep Track of ChangesHere’s the scenario: You have the first contract in your hand, and you’re ready to begin its review. If you have a paper copy, arm yourself with colored markers. Use a green highlighter to mark portions with a financial impact. Use a red marker for unacceptable areas to be addressed in your negotiations. Highlight in yellow the sections you don’t fully understand or needing further clarification. If you are reviewing an electronic version of the contract and use Microsoft Word, click the Track Changes button on the Review tab. This will allow you and everyone else who views the document to see any changes you made.
Tip 2: Look Out for Weasel WordsPay close attention to what attorneys refer to as “weasel words.” Terms such as “will use best efforts” or “will attempt” don’t carry much meaning in a contract. Make sure those areas are addressed and clearly defined.
Tip 3: Make a Checklist for DiscussionAnother good tool is a checklist with your particular requirements listed. As you encounter each provision, check them off. Anything on your list not checked should be discussed.
Tip 4: Negotiate With a SmileNow that you have your discussion checklist ready, what is the best approach for entering into negotiations? The old idiom says it best, “You can catch more flies with honey than with vinegar.” Be professional and non-adver-sarial. Separate yourself from the issues and weigh each proposal on its own merits.
Make it clear from the beginning what you have the authority to approve and what you’ll need someone higher up to approve.
Who initiated the request for the contract? If it was the payer, they want you in their network and are more apt to bargain than if you requested to be in their network.
Tip 5: Know the Bottom Line Know your direct costs for office visits and most-commonly billed procedures so you can talk dollars and establish your bottom line. Typical payment methodolo-gies include the following:
Discounted fee-for-service, where you are paid a percentage of your billed charges (not very common these days)
Payment based on the Resource-Based Relative Value Scale (RBRVS) unit value, usually expressed as a percentage of Medicare
Payment based on the insurer’s proprietary fee schedule.
In the final case, you’ll give the insurer a list of the most common CPT® codes you use and they’ll price the codes at their base value. You can then work on percentages of that base value.
Tip 6: Use the Coding Skills You HaveYour coding skills are an asset during contract negotia-tions. As coders, you have the perspective to think the pro-cess through to the end and to be sure the terms you agree on can be executed.
Suppose you work for a small but busy obstetrics practice. Your doctors don’t have their own equipment to perform fetal non-stress tests (NST) (59025 Fetal non-stress test), but use the equipment in the local hospital’s labor and deliv-ery department. It is costly and time-consuming for your physicians to go to the hospital to perform an NST every time a patient shows up with a possible complication. It would be best to negotiate with a payer to reimburse an additional 25 percent over and above the usual rate for an unscheduled NST.
Sounds like good negotiating; however, it prompts ques-tions. How do you suppose you’re going to get that pay-ment? You would bill 59025 with modifier 26 Professional component, with a Place of Service (POS) of 22 Outpatient hospital, but how can you identify this as an unscheduled test versus a scheduled one?
During negotiations is the best time to find out if the payer has a system capable of triggering the higher pay-ment. They might say to bill 59025-26 with a second
PR
OFE
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Stabilize Your Accounts Receivable
By David Peters, CPC, CPC-P, PCS, CCP-P
The next step toward concise contract negotiations is using effective communication.
www.aapc.com August 2009 13
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modifier of ET Emergency Services, or some other coding modification (59025-26-ET). Recognize and resolve poten-tial coding problem areas up front. (Note: This is why we’re never allowed to discuss payer-specific coding rules at seminars and meetings—whatever works out best for both parties usually ends up as how the service is coded, using standard procedures or not.)
Tip 7: Finish the JobYou may think when the contract is in its final revision and it has been signed by both parties at the appropriate level you’re done. Wrong.
Contracts require a little care and feeding. For instance:
Keep contracts centrally located in your office.
Create a tickler file for all contracts including termi-nation and anniversary dates and check it monthly to keep it current.
Make a copy of the payment terms and other pertinent information for your billing staff to ensure claims are billed correctly and correct payment is received.
If your billing system can be programmed with expected reimbursement, spend the time and money to do so.
Provide the front desk staff with a current list of what insurances you accept in your office. Noth-ing will anger a patient quicker than hearing “Sure, we’ll bill your insurance for you,” and then receiving a bill for the visit’s full amount because the physi-cian is out of network. If your front desk and sched-uling staff have a list of contracted insurance plans, patients can be forewarned of a higher out-of-pocket expense or minimal coverage for insurance plans not under contract.
David Peters, CPC, CPC-P, PCS, CCP-P, is contracts manager for Sutter Medical Foundation - North Bay, in Santa Rosa, Calif.
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20 AAPC Coding Edge
By Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P
feature
Clinical documentation improvement plans (CDIPs) are a hot topic for 2009. CDIPs are a collaborative
process among providers and coders to bridge the gap between the data contained in the medical record and what is necessary for complete and proper coding.
Documentation quality is vital to nearly every aspect of health care; and, accurate chart documentation and diagnosis reporting now determines reimbursement for the Centers for Medicare & Medicaid Services’ (CMS) Medicare Advantage (MA) plans under the risk adjust-ment program. (If you aren’t familiar with Medicare’s risk adjustment program, please see the accompanying sidebar “What is Medicare Risk Adjustment?”)
CMS conducts medical record reviews to validate and ensure the accuracy and integrity of the risk adjustment data submitted by the MA plan for payments. Every MA organization may be randomly selected, or targeted, to participate in the medical record review. To be prepared, you should assume that, sooner or later, CMS will audit your medical records, and potentially your program.
The risk adjustment data validation process verifies that diagnosis codes submitted for payment by the MA orga-nization are supported by medical record documentation for an enrollee.
Recent CMS validation findings indicated coded condi-tions were not supported in approximately 30 percent of the records reviewed.
Come Up With a PlanDeveloping a CDIP requires you to take specific steps to improve your documentation and coding performance. The following four points will get you started.
1. Understand Clinical DocumentationCurrently, MA health plans are reimbursed based on beneficiaries’ chronic conditions. Submitting an inaccu-rate diagnosis, or a diagnosis resulting in a different hier-archical condition category (HCC), is a compliance risk. Any change in the HCC could mean you are receiving too much or too little revenue. Either way, the code could not be validated and is considered discrepant.
An understanding of clinical documentation’s role and its impact on CMS-HCC enables one to see the big picture. Important points include:
Well-documented medical records facilitate com-munication, coordination, and continuity of care, and promote the efficiency and effectiveness of treatment.
Accurate coding is the key to prompt reim-bursement, practice profiling, and contract negotiations. It is important for both financial and compliance reasons.
Chronic conditions are important to show resource utilization, as well as severity of illness for statistical purposes.
Validate Coding Data with CDIPsin Medicare Risk AdjustmentPolish your coding knowledge and skills.
EXPE
RT
www.aapc.com August 2009 21
Whatever specific tools you adopt, ongoing education and buy-in from the providers are essential.
feature
Being as specific as possible is important for further research into treatment effectiveness for chronic conditions.
Showing medical necessity justifies your treat-ment choice and helps support evaluation and management levels.
2. Evaluate Ways to Improve Clinical DocumentationThere may be opportunities within your current pro-cess to capture a more appropriate CMS-HCC code. For instance, consider this list of the top 10 coding errors for risk adjustment:
1. The record does not contain a legible signature with credential.
2. Electronic medical record (EMR) was unauthenti-cated (not electronically signed).
3. Lack of specificity: Always assign the most pre-cise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.
4. A discrepancy was found between the diagnoses codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Episodic mood disorders; major depressive disorder, single episode, unspecified), these codes do not match; they map to a different HCC cat-egory. The diagnosis code and the description should mirror each other.
5. Documentation does not indicate that the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
6. Status of cancer is unclear. Treatment is not docu-mented.
7. Chronic conditions, such as hepatitis or renal insuf-ficiency, are not documented as chronic.
8. Lack of specificity (eg, an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
9. Use of “unspecified” codes (eg, an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
10. A link or cause relationship is missing for a diabetic complication or there is a failure to report a manda-tory manifestation code.
Regardless of where you find shortcomings in your facil-ity, you should consider ways to improve clinical docu-mentation. Develop a compliance plan and implement prospective and retrospective, internal and external chart reviews with ongoing monitoring and feedback. Be sure to review the record based on official coding guidelines.
Many plans use analytics to detect beneficiaries who might have missing diagnosis codes based on the analysis of pharmacy, claims, and durable medical equipment (DME) data. Analytics are a good tool to point you in the right direction, but they are not a silver bullet to fix missing diagnosis code issues. Even if analytics identify a patient is missing a diagnosis, and the medical record indicates the patient has the condition, often the doctor has not documented the condition in the appropriate manner (MEAT, etc.) which, from a coding guideline perspective, means that code can’t be submitted.
Prospective chart reviews reduce the chance of submit-ting invalid or non-specific diagnoses codes to CMS, and also reduce providers’ compliance risk. Implementing a review program allows you to identify problem areas quickly, and identify opportunities for provider education and interaction.
The medical record should tell a story. Coding special-ists need to understand what the physician is thinking and know when the provider isn’t documenting the com-plete information necessary to assign the most specific diagnosis code. Identify all documentation improvement opportunities.
When target areas are identified, work with providers and staff to provide timely education and training to pro-mote change.
3. Offer Solutions to Prompt Excellent DocumentationIdentifying problem areas is only part of the battle. Translating this knowledge into improved documentation practices produces the real results.
Physicians have an overwhelming career, so whenever possible, provide simple solutions and tools to encour-age necessary documentation. Tools meeting compli-ance standards for reimbursement provide continuity of patient care and allow the provider to do what he or she does best—provide quality medical care to patients. For instance, consider implementing templates, when appro-priate, that prompt providers to document the status of chronic conditions.
22 AAPC Coding Edge
feature
Keep all your materials—including superbills or encounter documents, and internal policies and procedures—up-to-date.
For the medical record to be accurate and timely, a phy-sician query process should be in place. Ongoing chart reviews and provider education reinforces good documen-tation and helps bridge the gap between what the pro-vider needs clinically documented in the medical record from one visit to the next, and the coding guidelines required to support submitted codes.
You may try a variety of methods to improve documenta-tion, monitoring their effectiveness and value, and then select the methods that work best with your providers and staff.
Whatever specific tools you adopt, ongoing education and buy-in from the providers are essential. Continue to stress to providers the importance of coding and docu-mentation—how they affect reimbursement, and how they are used to evaluate the quality of health care facili-ties across the country [pay for performance (P4P), and Physician Quality Reporting Initiative (PQRI)].
4. Analyze the ResultsYou’ve convinced providers and staff of the importance of complete documentation and coding; and you’ve identi-fied potential problem areas and implemented programs to correct those problems. Now it’s time to evaluate the
results of your program to ensure its effectiveness.
Ongoing record review and provider education reinforces the essential points of good documentation. Utilize the documentation guidelines as your benchmark criteria.
Remember: The review’s purpose is to validate whether the medical record documentation supports the codes submitted.
Compile coding processes and results to determine where improvements could be made in method, effectiveness, and structure. Timely feedback is essential to facilitate a change in behavior.
Finally, keep up your efforts. Provide ongoing, periodic education, including yearly ICD-9-CM updates, to ensure your documentation and coding stay on track.
Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P, CCDS, is director of educa-tion and consulting services for The Coding Source, LLC. Carol oversees the MRA Coding and Education Division, managing 150 medi-cal coders. She has 30 years health care experience in both private and public sec-tors, has conducted various risk adjustment
coding and documentation trainings nationwide, and has taught the Professional Medical Coding Curriculum (PMCC) to hundreds of students. Contact her at [email protected].
www.aapc.com August 2009 23
feature
What is Medicare Risk Adjustment?Medicare risk adjustment determines Medicare Advantage (MA) reimbursement or managed care enrollees’ health expenditures according to the severity of individual patient’s illness. This in turn drives treatment costs and resource use. Payments are higher for unhealthy members, lower for healthy beneficiaries.
The Balanced Budget Act of 1997 mandated risk adjustment methodology to improve payment accuracy and to strengthen the Medicare program. The methodology was fully implemented for MA in 2007. Payments are currently adjusted based on a calculation of chronic medical conditions, plus five demographic factors:
1. Age;
2. Sex;
3. Medicaid status;
4. Disabled status; and
5. Original reason for entitlement.
The Medicare risk adjusted reimbursement model is based on chronic, additive conditions, or hierarchical condition categories (HCCs). There are two types of HCC models:
Part C (Managed Care): MA published the final rate 2004 payments in December 2003. The CMS-HCC predicts plan liability.
Part D (Prescription Drug): Prescription (RX) Drug model announced the final Part D payments in April 2005. The RX-HCC predicts plan liability for prescription drugs.
Historically, physicians and medical groups focused on CPT® coding because procedural codes drove reimbursement. ICD-9-CM codes are the basis of the CMS-HCC model, however, and drive payments from CMS for MA beneficiaries.
There are more than 3,000 ICD-9-CM codes adjust risk, but only 70 HCC groups. Diagnosis codes are categorized into disease groups to include clinically related conditions with similar cost implications. The model is influenced heavily by chronic disease costs. Payments are based on the most severe disease manifestation when less severe manifesta-tions also are present.
For instance, if a newly-diagnosed diabetic patient hasn’t developed any complications, you would code diabetes (250.00 Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled). If that patient develops a complication—such as diabetic neuropathy—the provider should document and code diabetic neuropathy (250.60 Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled, 357.2 Inflammatory and toxic neuropathy; polyneuropathy in diabetes), as it is a more severe manifes-tation of the disease.
Financial losses due to incomplete documentation or diagnosis coding can add up quickly. For example, annual reim-bursement for 250.00 is $1,573 and for 250.60, 357.2 it’s $3,963. The difference in compensation to the health plan based on the severity of the patient’s diabetes is $2,390 annually.
The Risk Adjustment Factor (RAF) is a score identifying a patient’s health status. The RAF resets each Jan. 1, so chronic conditions must be documented, coded, and submitted at least yearly for each beneficiary. Otherwise, patients’ health statuses are not reflected accurately and the health plan is at risk of low RAF scores. This is important because CMS compensates the health plan a per-member premium that supports the provider’s contracts, disease management, case management, preventive services, and other services that typically are not covered benefits for Medicare members, but are covered benefits for the managed care or MA beneficiaries.
Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P
To discuss this article or topic, go to member
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hot topic
For coders in the payer venue, the world is different. They review claims and work in coordination of benefits staff,
auditors, utilization management, billing services, provider rela-tions, contracting, or customer service. Payer coders also verify coding accuracy and correct reimbursement. The AAPC has updated the Certified Professional Coder-Payer (CPC-P®) exam and created a new preparation guide to assure you have the skills to address coding issues unique to the payer world.
Settle Payer/Physician Coding DifferencesJulia Croly, MPA, CPC, CPC-P, director for Underwriting and Analytical Services, Blue Cross and Blue Shield of North Carolina, said, “The CPC-P® certification solidifies one’s knowledge of the current payer environment and, at the same time, allows us to partner with physicians to attain a goal of seamless claims payment.”
Coding for a payer requires knowledge of payment methodolo-gies and coding expertise that is different from the physician side. Susan Goldsmith, CPC, CPC-H, CPC-P, CPC-I, CCS-P, CCP and CPEHR, owner of SG Consulting Services Inc., Phoe-nix, Ariz., is an expert on the payer end of coding/billing and acknowledges the unique payer coding requirements. “Coders submitting claims on behalf of physicians use coding conven-tions to describe all the services the physician provided,” said Goldsmith. “Coders at the payer side, however, must also know how those codes are utilized to determine payments for those services.”
For example, payer-side coders need to know:
Rules regarding bundling of services;
When to reduce payments for multiple services;
Which services require additional professionals (such as assistant surgeons’);
How to determine proper payment for those addi-tional professionals; and
How to identify services that are included in global payments and are not eligible for separate payment.
The CPC-P® credential can help prepare payers to “correctly process claims, review claim patterns to detect inappropriate claiming, review and determine the validity of claim disputes, design payment systems, assist with actuary studies of service utilization, and perform contract administration and data analy-sis duties,” Goldsmith said.
CPC-P® Moves You Up in the Payer WorldIf you are coding at a commercial or federal payer, you should consider earning the CPC-P® credential. The CPC-P® credential verifies that a coder “understands how coding translates into proper payment, which can expand a coding professional’s potential employment opportunities within a payer organiza-tion,” she said.
The CPC-P® demonstrates the payer coder’s aptitude, profi-ciency, and knowledge of coding guidelines and reimbursement methodologies for all types of services from the payer’s perspec-tive. AAPC National Advisory Board (NAB) President-elect Jonnie Massey, CPC, CPC-P, CPC-I, AHFI, Legal Division, super-visor, external audit and investigations of the Regence Group, said that the CPC-P® credential helped her professionally by
recognizing she has the skills to correctly answer pressing coding and reimbursement issues unique to payers. “In these challenging economic times, demonstrating a willingness to pursue excellence through the CPC-P® credential is vital to both my career and employer. By taking the extra steps to earn this credential, I have demonstrated I am willing to go above and beyond the minimum required work.”
Power-up for the Payer Coding ExamThe CPC-P® Study Guide covers appropriate coding and typical industry standard edits to demonstrate how they work in conjunction with various reimbursement meth-odologies for physician services, outpatient services, and inpatient services. The study guide also reviews health insurance concepts, HIPAA and concepts related to CPT®, HCPCS Level II, and ICD-9-CM coding.
Practice exams feature 30 questions taken online with immedi-ate test results. Incorrect answers display with correct choice rationales to help you learn. Practice exams emulate the content and difficulty level of the actual exam, so they are a realistic indicator of your readiness. You can take the practice exams as many times as you want until you feel confident to pass the exam.
Goldsmith is developing a three-day workshop course curricu-lum for individuals planning on taking the CPC-P® exam. For more information, payers may contact her via e-mail at [email protected].
Test Your Payer Coding SkillsThe CPC-P® exam certifies knowledge to adjudicate provider claims effectively. The exam tests coding-related payer func-tions and how those functions differ from provider coding. The CPC-P® exam:
Is a 5½ hour, open book, proctored exam.
Consists of 150 multiple choice questions sepa-rated into two parts: The Medical Coding Concepts section tests the medical terminology, anatomy, and CPT®, HCPCS Level II, and ICD-9-CM coding concepts; and, the Reimbursement Methodologies section covers physician reimbursement, inpatient payment systems, outpatient payment systems, health insurance concepts, and Health Insurance Portability and Accountability Act (HIPAA).
Costs $300 ($260 AAPC students), and you have one free retake if you don’t pass the exam.
Contributing developers of the exam include Dr. Marc Lieb, M.D., J.D., as well as a number of well-known CPC-P®s in the payer community.
Certification RequirementsAs of January 2009, all exams are reported with exact scores. The CPC-P® exam will report the top three areas of weakness. A CPC-P® must have at least two years medical coding experi-ence and maintain yearly renewal as well as submit 36 continu-ing education units (CEUs) every two years for verification and authentication of expertise.
For more on obtaining and maintaining the CPC-P® credential, go to www.aapc.com/certification/cpc-p.aspx.
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24 AAPC Coding Edge
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26 AAPC Coding Edge
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When electronic health records (EHRs) were first promoted, you may have been led to believe they could singlehandedly reduce medical errors, promote standardization of care, reduce costs, and increase physician efficiency. Physicians would be able to see as many, if not more, patients than they could pre-EHR and document all of it in an instant before ever leaving the exam room. No more chart stacks on desks at the end of each day; no more staying up late completing dictation or handwriting notes. That got physicians’ attention.
Now that EHRs are a reality, however, many physicians are finding they aren’t as magical at streamlining documentation as advertised. The issues associated with documentation in EHRs include:
There’s a learning curve to using the software.
Physicians must find lab results on patients somewhere in each electronic chart, rather than asking the nurse to call the lab to fax the results.
Physicians must navigate unfamiliar territory just to doc-ument the four simple letters “NKDA” (no known drug allergies).
But the biggest surprise comes after the documentation is done—the physician has to code it. Physicians were initially told the EHR system would automatically choose the codes at the press of a button.
Documentation Must Reflect Code SelectionWith the roll-out of EHRs, you may have found yourself in the same situation as many coders. Consider, for instance, the following scenario:
In pre-EHR days, the physician could dictate diabetes mel-litus (DM). The coder would look through the documentation to choose the type of diabetes mellitus and report the appro-priate ICD-9-CM code.
If the physician documents DM in the EHR, by contrast, she
is confronted with a list of ICD-9-CM codes from which to choose, including fourth and fifth digits to describe the type of diabetes mellitus. The patient may have hypoglycemia, as well, so the physician chooses what she believes is the perfect diagnosis: 250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled.
The physician may not realize, however, the importance of doc-umentation matching the diagnosis code being billed. Unfortu-nately, what the documentation is missing for the service date is any mention of the DM being “uncontrolled,” or that the patient has hypoglycemia. Both of these conditions should be reflected in the note if ICD-9-CM code 250.82 is to be billed.
Physicians Decide Appropriate E/M LevelAnother factor left up to physicians is choosing the appropriate evaluation and management (E/M) level in the EHR.
The EHR may give the physician E/M level suggestions based on the documentation for that service date. The physi-cian still must know the basic elements required for each E/M visit level, as well as the requirements to bill a con-sultation or how to distinguish a new patient visit from an established patient visit.
Further questions arise in the exam portion of the E/M ser-vice. The parameters your EHR system follows determine if the physician has, for example, completed an expanded problem-focused exam versus a detailed exam. The difference can be the EHR suggesting your physician bill 99213 rather than 99214.
Another consideration is whether the EHR counts the medical decision making (MDM) level as one of the key components before choosing the E/M service level.
For instance, for an established patient office visit you are required to meet at least two out of three key components: history, exam, and MDM. Let’s say your physician uses an EHR template for a normal history and exam, which have
EHR PitfallsKeep Coders on Their ToesCoders and physicians alike are finding electronic health records aren’t the magic bullet.
By Ronda Tews, CPC, CHC, CCP-P
www.aapc.com August 2009 27
cover
enough elements to meet a 99214 (detailed history and detailed exam). The MDM was straightforward because it was a simple sore throat with no additional work-up and no pre-scribed drugs or tests.
Is your physician and practice comfortable with billing 99214 based on the detailed history and detailed exam, or are they more conservative and likely to lean toward a 99213 or 99212 based on the MDM’s content?
These are a couple of reasons why the physician should know the basic elements required for each E/M visit level prior to choosing and/or prior accepting the E/M level suggested by the EHR.
Use Timesaving Templates with Caution Using a template or cutting and pasting portions of the three key components can be very timesaving for the physician; however, this should be done with great caution. You do not want a physician to use the same review of systems (ROS) or history on every patient they see. This could be construed as a “canned note,” and not specific to each individual patient’s distinctive problems. An indication of this occurring is when you see documentation like this:
ROS: CONST: No complaint of weight loss, fatigue, chills, or fever.
PULM: No complaints of cough, hemoptysis, wheeze, or SOB.
CV: No complaints of chest pain, angina, orthopnea, or PND.
FINAL DIAGNOSIS: Malaise and Fatigue.
This creates an EHR with conflicting information. The final diagnosis indicates the patient was seen for malaise and fatigue. The documentation, however, states the patient has no complaint of fatigue. It would appear the physician used her normal ROS template, but did not make any modifica-tions to it.
The physician is permitted to use a template, or to cut and
paste certain information, as long as the action was performed by the physician and the information is correct and specific to that patient’s visit on that service date. This means the physi-cian always needs to proofread the template and modify cer-tain elements to make it specific to each patient’s visit.
A Coder’s Role in EHRHere’s where you, the coder, step in. Your coding knowledge is necessary to set up the EHR, to educate the physicians, to verify accurate documentation, and to maintain consistent coding. The EHR is a documentation tool, not a coding tool. A coder’s expertise is necessary to evaluate documentation clarity, consistency, and completeness. The coder will always be the mediator between the documentation and the bill that goes out the door, regardless of whether the documentation is handwritten, transcribed, or electronic.
A coder’s job isn’t finished when the bill goes out the door. Take into account all of the groups contracting with federal and state agencies to search for evidence of improper bill-ing and overpayments. You have the alphabet soup of RACs, MACs, ZPICs, MICs, and most recently, HEAT. Physicians and facilities benefit by employing coders to review records requests and verify that the necessary documentation is pres-ent and supports what is being billed.
This is not to naysay EHRs. If you account for the learn-ing curve and allow sufficient time for everyone involved to acclimate themselves to the new system, EHRs offer endless capabilities and wonderful reporting features. The important thing to remember is that EHRs aren’t magic. To deliver superior results, coding know-how and sound judgment is required.
Your coding knowledge is necessary to set up the EHR, to educate the physicians, to verify accurate documentation, and to maintain consistent coding. The EHR is a documentation tool, not a coding tool.
Ronda Tews, CPC, CHC, CCP-P, is a corporate com-pliance project manager with St. John’s Health System in Springfield, Mo.
To discuss this article or topic, go to member
http://forums.aapc.com
28 AAPC Coding Edge
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To minimize a patient’s financial responsibility when paying for vision care, you should understand when
it’s appropriate to bill a medical exam versus a routine vision exam. Knowing the difference, and clearly com-municating it to patients prior to rendering services, can save you a lot of time educating the patient—and some-times the payer—as to why the claim processed the way it did.
Understand Medical Plans vs. Vision PlansAlways bill an evaluation of an acute complaint, a full exam for an existing medical condition, or a consultation for a medical complaint to the patient’s medical plan. Exams to check normal or healthy vision, screening for eye diseases, or an exam to update eye glasses or contact lenses should be billed to the patient’s vision plan.
ICD-9-CM code V72.0 Examination of eyes and vision and screening codes, such as V80.1 Special screening neurologi-cal, eye, and ear diseases; glaucoma, are examples of diagno-sis codes you should submit to a vision plan for a routine eye exam. Most payers, including Medicare, do not recog-nize the majority of diagnosis codes in the 367 Disorders of refraction and accommodation code set as medical reasons for an eye exam. These codes indicate refractive errors such as myopia, astigmatism, and presbyopia.
Often, a medical condition found during a routine eye exam supersedes a routine diagnosis. This holds true for optometrists who perform routine eye exams and encoun-ter a medical problem during that exam. Clearly explain this to patients at the time services are rendered.
Shed Light on Patient CoverageMake patients aware of coverage limitations when they present for a routine exam that subsequently becomes medical in nature. A patient can become confused when he or she finds an exam isn’t covered by insurance. If a patient is insistent that you resubmit a claim, tactfully decline and review the medical record with the patient—pointing out the chief complaint and how the physician addressed those complaints. If applicable, remind the
patient of any testing done and the findings.
Resubmitting a claim to assist a patient in avoiding financial responsibility is not appropriate. Providing a clear explanation to the patient—even if he or she still is dissatisfied with your decision not to resubmit a claim—will help the patient understand your position.
Medicare does not cover routine annual exams. Beneficia-ries may choose to have an annual exam but if there isn’t a medically necessary reason for the visit a beneficiary is responsible for the cost. Asking the patient to sign an advanced beneficiary notice (ABN) for such visits isn’t necessary because routine care is considered a non-covered service and clearly indicated by Medicare law. It is the beneficiaries’ responsibility to understand the limitations of Medicare coverage.
As private fee-for-service plans enter the market, they are expanding their covered services to beneficiaries to remain competitive. This can include covering routine eye exams. Just as you would treat a patient with com-mercial coverage, you should make sure beneficiaries are familiar with their plan’s coverage limitations.
Know Carrier LimitationsPrior to 1996, commercial payers could create and use their own code sets for many services, including routine eye care exams. After Health Insurance Portability and Accountability Act (HIPAA) implementation, some payers replaced their routine eye codes with HCPCS Level II codes.
Codes S0620 Routine ophthalmological examination including refraction; new patient and S0621 Routine ophthalmological examination including refraction; established patient specifi-cally describe routine eye exams, including refraction.
You would use these codes for healthy patients who pres-ent for routine eye exams for new eyeglasses or contact lenses. Medicare doesn’t accept these codes; however, commercial plans, such as Aetna, recognize these codes and would expect them to be present on the claim for a true routine eye exam.
Exam Level Matters in OphthalmologyKnowing when to bill a medical exam versus a routine vision exam ensures proper reimbursement.By Jennifer Worthy, CPC, OCS
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www.aapc.com August 2009 29
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If your ophthalmology practice accepts both medical and vision plans, you may submit claims to both payers in certain situations. A patient may, for example, pres-ent for a routine eye exam with refraction at which time a medical condition is identified. In this case, one of two things can happen.
The patient may choose to continue with the routine eye exam, as covered by a vision plan, and return at a later date for treatment of the incidental finding. If so, you would bill the subsequent exam to monitor or treat the medical condition to the patient’s medical plan.
The patient may choose to proceed with the medical exam. If so, you should make the patient aware that his or her plan may have exclusions and/or limitations that require an applicable specialist co-payment, primary care physician referral (when required), deductable, and/or co-insurance.
Although some major medical plans allow a benefit for routine eye exams, the patient needs to understand the terms of his or her coverage, and at what point a routine exam turns medical, to avoid confusion.
In any case, the exception to this would be an emergency or urgent condition where delaying treatment is not an option to the physician or optometrist.
Restore 20/20 VisionWhether you are in an optometry practice or ophthal-mology practice, understanding the reason for a patient’s visit will limit confusion. Remember that patients often don’t understand the difference between optometric care and ophthalmology care. Patient education and consis-tency among staff to understand limitations of coverage can also help alleviate any confusion for the patient. Developing a system within your practice to alert clerical and clinical staff about the limitations of a patient’s cov-erage is an effective way to avoid any miscommunication later on with a patient.
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Jennifer Worthy, CPC, OCS, is a patient account specialist for Eyecare Medical Group in Portland, Maine. She enjoys the chal-lenge of coding in an environment that offers a range of billable services. She has been in the ophthalmology field for six years.
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Coding Edge received helpful feedback regarding moving the Test Yourself feature solely to the AAPC Web site. Even though tens of thousands of members found the on-line exam preferable to the printed version over the last year, some of you let us know you preferred paper. Here are some answers to the most common questions:
Why did you do this?Over the last year, we’ve offered the on-line Test Yourself on the AAPC Web site, and members have reported back they like the interactive quality that includes rationales for the answers and immediate logging of their CEUs on the CEU Tracker. We’ve also wanted to add more pages about coding to the magazine, and hope the extra coding information will prove beneficial.
Can I still get CEUs for Coding Edge?Of course! All you need to do is answer the questions on-line, and your CEUs will be automatically recorded for you on the CEU Tracker.
Where is it?Go into the member page and click on the Coding Edge cover, or follow this link: https://www.aapc.com/MemberArea/resources/coding-edge/index.aspx
But I like a paper version to write on when I read the magazine or to have when my friends and I get together to do the Test Yourself questions. The questions are easy to print off. Just go to the link, bring up the questions, and press CTRL and P (if you’re using a PC) and COMMAND and P (if you’re using an Apple). You’ll then have a printed page on which you can write notes and answers. Remember to go back on line to get your CEUs!
I don’t have access to a computer. Call AAPC Customer Service at 1-800-626-2633 (CODE), and we can help.
test yourself FAQ
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added edge
In this three-part series on the driving components of level selection for the majority of evaluation and management (E/M) services, we discuss history, exami-nation, and medical decision making (MDM). In this final installment, we’ll focus on the MDM component.
MDM is perhaps the most important of the three primary components of E/M code selection. It is also the most subjective. Whether you use the 1995 or 1997 E/M documentation guidelines, the nature of the presenting problem and the medical necessity of the encounter are the best MDM indicators. You will choose an overall MDM level based on three factors: the number of diagnoses or management options; the amount and/or complexity of data to be reviewed; and the risk of complications and morbidity or mortality.
Count Diagnoses or Management OptionsThe number of diagnoses or management options is based on the relative difficulty level in making a diag-nosis, and the status of the problem. Although audit tools vary, the number of diagnosis and management options is typically determined using a points system. Under this system, points are assigned according to not only how sick a patient is, but the amount of physician work involved.
Minor problems, such as those that would resolve regardless if the patient had sought medical atten-tion, are worth one point. A patient may have four minor, documented problems. But for coding pur-poses only a maximum of two such problems can be counted.
Established, stable, or improved conditions are worth one point each.
Established, worsening conditions are worth two points each.
A new problem (new to the patient or new to the provider) without any additional workup is worth three points. You may only count such a problem once per encounter, even if there are multiple occurrences in the encounter.
A new problem with additional workup is counted as four points.
A workup is defined as anything the physician had to do after making the diagnosis the patient left with on that day. For example, if the physician suspects a par-ticular diagnosis and sends the patient on for a diag-nostic test to confirm that suspicion, that diagnostic test would count as workup.
There are four levels of MDM defined by CPT®, and four corresponding diagnosis and treatment level options:
Straightforward MDM requires a minimal number of diagnosis and treatment options which correlate to (at least) a detailed work level. For both the 1995 and 1997 documentation guidelines, the number of diagno-sis and management options is minimal if the sum is one point.
Low MDM requires a limited number of diagnosis or treatment options. For both the 1995 and 1997 docu-mentation guidelines, the number of diagnosis and management options is low if the sum is two points.
Moderate MDM requires a moderate number of diag-nosis and treatment options. For both the 1995 and 1997 documentation guidelines, the number of diagno-sis and management options is moderate if the sum is three points.
High MDM requires an extensive number of diagno-ses or treatment options. For both the 1995 and 1997 documentation guidelines, the number of diagnosis and management options is high if the sum is four or more points.
For example, a level four new patient visit (99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity) requires a mod-erate level of MDM. To meet the work of moderate MDM, a moderate number of diagnosis and/or treat-ment options (three points total) must be documented.
Point to Data Amount and ComplexityThe amount and complexity of data for review is mea-sured by the need to order and review tests, and the need to gather information and data. Planning, sched-uling, and performing clinical labs and tests from the
By Katherine Abel, CPC, CPC-I, CMRS
The Driving Parts of E/M Level Selection
www.aapc.com August 2009 33
added edge
medicine and radiology portions of CPT® are indications of complexity, as is the need to request old records, or to obtain additional history from someone other than the patient (such as a family member, caregiver, teacher, etc). Documented discussions with the performing physician about unusual or unexpected patient results may also result in credit.
If a physician makes an independent visualization and interpretation, for example, with an MRI film or a Gram stain—and he or she is not billing separately for that service—it would be credited in this component of code selection.A points system is very effective for mea-suring the amount and complexity of data for review:
Clinical labs ordered or reviewed are worth one point.
Any test(s) reviewed/ordered from the medicine section of the CPT® book are worth one point.
Any procedures reviewed/ordered from the radi-ology section of the CPT® are worth one point. Regardless of the number of radiological proce-dures reviewed/ordered, only a total of one point may be assigned (e.g., five radiology reports reviewed count as one point only).
Discussing patient’s results with the performing or consulting physician is worth one point—if it is captured in the documentation.
Decisions to obtain old records or additional his-tory from someone other than the patient are worth one point.
Review and summary of data from old records or additional history gathered from someone other than the patient is worth two points.
Independent or second interpretation of an image tracing or specimen is worth two points. Note that this means not just the review of the report, but of the actual film image or tracing.
There are four MDM levels defined by CPT®, and four corresponding data amount and complexity levels:
Straightforward MDM requires a minimal amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity
of data is straightforward if the sum of this data is zero or one point.
Low MDM requires a limited amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity of data options is low if the sum is two points.
Moderate MDM requires a moderate amount and complexity of data. For both the 1995 and 1997 docu-mentation guidelines, the amount and complexity of data options is moderate if the sum of this data is three points.
High MDM requires an extensive amount and com-plexity of data. For both the 1995 and 1997 documen-tation guidelines, the amount and complexity of data options is high if the sum is four or more points.
For example, a level four new patient visit (99204) requires a moderate MDM level. To meet the work of moderate MDM, a moderate amount and complexity of data (three points) must be documented.
Turn to the Table of RiskRisk is measured based on the physician’s determina-tion of the patient’s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. Risk indi-cations include the nature of the presenting problem, the urgency of the visit, co-morbid conditions, and the need for diagnostic test for surgery.
Documentation guidelines determine the risk level using the Table of Risk (see accompanying Table of Risk). The Table of Risk is divided into three columns; each column correlates with an overall risk level. The three columns list presenting problems, diagnostic pro-cedures ordered, and management options selected.
There are four levels of MDM defined by CPT®, and four corresponding risk levels:
Straightforward MDM requires a minimal risk level. For both the 1995 and 1997 documentation guidelines, a straightforward level or risk corresponds with any of the columns in the Table of Risk that are labeled “minimal risk.”
Low MDM requires a low risk level. For both the
If a physician needs to make an independent visualization and interpretation, for example, with a magnetic resonance imaging (MRI) film or a Gram stain—and not billing separately for that service—the independent visualization and interpretation is credited in this component of code selection.
34 AAPC Coding Edge
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1995 and 1997 documentation guidelines, a low level or risk corresponds with any of the columns in the Table of Risk that are labeled “low risk.”
Moderate MDM requires a moderate risk level. For both the 1995 and 1997 documentation guidelines, a moderate level or risk corresponds with any of the columns in the Table of Risk that are labeled “moder-ate risk.”
High MDM requires a high risk level. For both the 1995 and 1997 documentation guidelines, a high level or risk corresponds with any of the columns in the Table of Risk that are labeled “high risk.”
For example, a level four new patient visit (99204) requires a moderate risk level. To meet the work of moderate MDM, a moderate level or risk (as deter-mined using the Table or Risk) must be documented.
Elements Drive Overall MDM LevelTo select an overall MDM level, at least two of three elements (number of diagnoses or management options; amount and/or complexity of data to be reviewed; risk of complications and/or morbidity or mortality) for that
level must be met.
For example, moderate complexity MDM requires two of the following three elements:
Multiple diagnoses or management options (a total of three points when using the points system described in this article)
Moderate amount and/or complexity of data to be reviewed (a total of three points when using the points system described in this article)
Moderate risk of complications and/or morbidity or mortality, as defined by the Table of Risk.
Next month in Coding Edge, we’ll pull together all the information on history, exam, and MDM we’ve reviewed to illustrate proper reporting of overall E/M level selec-tion in various outpatient and inpatient settings.
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Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered
Management Options Selected
Minimal One self-limited or minor problem, eg, cold, insect bite, tinea corporis
Laboratory tests requiring venipuncture
Chest x-raysEKG/EEGUrinalysisUltrasound, eg, echocardiographyKOH prep
RestGarglesElastic bandagesSuperficial dressings
Low Two or more self-limited or minor problems
One stable chronic illness, eg, well controlled hyperten-sion, non-insulin dependent diabetes, cataract, BPH
Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain
Physiologic tests not under stress, eg, pulmonary function tests
Non-cardiovascular imaging studies with contrast, eg, barium enema
Superficial needle biopsiesClinical laboratory tests requiring
arterial punctureSkin biopsies
Over-the-counter drugsMinor surgery with no identified
risk factorsPhysical therapyOccupational therapyIV fluids without additives
Moderate One or more chronic ill-nesses with mild exacerba-tion, progression, or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, eg, lump in breast
Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis
Acute complicated injury, eg, head injury with brief loss of consciousness
Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsy Cardiovascular imaging studies with
contrast and no identified risk fac-tors, eg, arteriogram, cardiac cath-eterization
Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, cul-docentesis
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors
Prescription drug managementTherapeutic nuclear medicineIV fluids with additivesClosed treatment of fracture or
dislocation without manipulation
High One or more chronic ill-nesses with severe exacerba-tion, progression, or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, pro-gressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure
An abrupt change in neuro-logic status, eg, seizure, TIA, weakness, sensory loss
Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological testsDiagnostic Endoscopies with identi-
fied risk factorsDiscography
Elective major surgery (open, percutaneous or endoscopic) with identified risk factors
Emergency major surgery (open, percutaneous or endoscopic)
Parenteral controlled substancesDrug therapy requiring intensive
monitoring for toxicityDecision not to resuscitate or to
de-escalate care because of poor prognosis
added edge
To discuss this article or topic, go to member
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Table of Risk
36 AAPC Coding Edge
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By now, you’ve probably heard the Centers for Medi-care & Medicaid Services (CMS) will offer incentives
to physicians who adopt electronic prescribing (e-pre-scribing). What you may not know is how easy it is to become involved.
E-prescribing transmits prescription or prescription-re-lated information from the prescribing physician (or other qualified professional) to the dispenser and pharmacy benefit manager or health plan using electronic media. The process may occur directly or by way of an interme-diary system (an e-prescribing network).
CMS supports e-prescribing in a big way: “Developing the standards that will facilitate e-prescribing is one of the key action items in the government’s plan to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States.” (www.cms.hhs.gov/eprescribing/)
Eligible professionals who successfully meet e-prescribing requirements for professional services, covered under Medicare Part B and provided during the reporting period, will receive bonus payments equal to 2 percent of the total estimated charges for those services.
If you’re not already e-prescribing, now’s the time to get involved. You’ll enjoy the advantages of improved pro-ductivity and patient care. 2009 and 2010 are the only two years participants can qualify for the full 2 percent incentive. In 2011 and 2012, the financial incentives from CMS will fall to 1 percent of your total estimated charges for covered professional services. In 2013, the incentive will decrease further to 0.5 percent.
The e-prescribing initiative is part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). CMS published its final rule for e-prescribing in the April 2, 2008 Federal Register (http://edocket.access.gpo.gov/2008/pdf/08-1094.pdf).
The final rule provides three electronic tools for use in e-prescribing:
Formulary and benefit transactions: Gives prescribers information about which drugs are covered by a Medicare beneficiary’s prescription drug benefit plan.
Medication history transactions: Provides prescrib-ers with information about medications a beneficiary is already taking, including those prescribed by other provid-ers, to help reduce the occurrence of adverse drug events.
Fill status notifications: Allows prescribers to receive an electronic notice from the pharmacy telling them if a patient’s prescription has been picked up, not picked up, or partially filled, to help monitor medication adherence in patients with chronic conditions.
Note that the e-prescribing reporting measures are separate from and independent of the Physician Quality Reporting Initiative’s (PQRI) reporting measures. This means physicians may have a chance to receive two incen-tive payments: one for being a successful e-prescriber, and another for successfully submitting other PQRI measures. You do not have to participate in PQRI to participate in the e-prescribing incentive program.
How to Get InvolvedThere is no sign-up or pre-registration to participate in CMS’ e-prescribing incentive program, but you must meet the following requirements:
1. You must be an “eligible professional.” CMS defines an eligible professional as a:
Physician
Physical or occupational therapist
Qualified speech-language pathologist
Nurse practitioner
Physician assistant
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Adopt E-prescribing for Monetary IncentivesBy Rhonda Buckholtz, CPC, CPC-I, CGSC, CPEDC, COBGC, CENTC
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Clinical nurse specialist
Certified registered nurse anesthetist
Certified nurse midwife
Clinical social worker
Clinical psychologist
Registered dietitian
Nutrition professional
Qualified audiologist
2. You must report one e-prescribing measure in at least half (50 percent) of the cases in which the mea-sure is reportable during 2009.
CPT® and HCPCS Level II G codes reportable under the e-prescribing initiative include 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G0101, G0108, and G0109.
You can find the complete eligible codes list for the e-pre-scribing initiative on the CMS Web site: www.cms.hhs.gov/PQRI/Downloads/2009ERXMadeSimpleFinal508.pdf.
3. Your estimated allowable Medicare Part B charges for the e-prescribing measure codes must equal at least 10 percent of the total Medicare Part B charges allowed.
For example: If your estimated allowable Medicare Part B charges equal $100,000, at least $10,000 of these charges must be based on the codes included in the e-prescribing incentive program measure.
4. You must use a qualifying e-prescribing system. There are two systems for e-prescribing: a stand-alone system, or an electronic health record (EHR). Either of these may qualify, as long as it can:
Generate a complete medication list that incorpo-rates data from pharmacists and benefits managers (if available).
Select medications, transmit prescriptions elec-tronically using standards and warn the prescriber of possible undesirable or unsafe situations.
Provide information on lower-cost, therapeutically appropriate alternatives (if available).
Provide information on formulary or tiered formu-lary medications, patient eligibility, and authoriza-
tion requirements received electronically from the patient’s drug plan.
5. Prescriptions must be sent electronically. If the phar-macy converts the e-prescription into a paper fax because it cannot receive electronic faxes, the physi-cian or other qualified professional still receives credit for e-prescribing. If your office has a system that is only capable of faxing to a pharmacy, however, you will not qualify for e-prescribing incentives.
6. You must report an appropriate numerator code (indi-cated below) in addition to a qualifying CPT® or HCPCS Level II G code on the claim you submit to Medicare.
If all of the prescriptions generated for the patient were sent via a qualified e-prescribing system, report G8443 Used a qualified e-prescribing system for all of the prescriptions.
If no prescriptions were generated for the patient during the visit, report G8445 Had a qualified e-pre-scribing system but didn’t generate any during this encounter.
If some or all of the prescriptions generated for the patient during the visit were printed or phoned in as required by state or federal law or regulations due to patient request or due to the pharmacy system being unable to receive electronic transmis-sion, or because they were for narcotics or other controlled substances, report G8446 Had a quali-fied e-prescribing system but prescribed narcotics or other controlled substance; State or Federal Laws required you to phone in or print the prescriptions; The pharmacy system could not receive electronic transmissions.
7. You must submit all claims no later than two months after the reporting period ends. For services provided in 2009, claims must be submitted prior to February 2010.
Remember, the sooner you participate in the e-prescrib-ing initiative, the greater your benefit. For additional information and complete instructions on e-prescribing initiative participation, visit the CMS Web site at: www.cms.hhs.gov/partnerships/downloads/11399.pdf.
If you’re not already e-prescribing, now’s the time to get involved … 2009 and 2010 are the only two years participants will receive the full 2 percent incentive.
Rhonda Buckholtz, CPC, CPC-I, CGSC, CPEDC, COBGC, CENTC is AAPC’s liaison, director of business and member development.
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Valorie Lynn Hill, CPC-A Smithville OHEllen Marie Thomas, CPC-A Sullivan OHJaclyn Ambor Putt, CPC-A Wadsworth OHRachael M Bowersock, CPC-A, W. Salem OHBrittany Lee Brittain, CPC-A Wooster OHLinda K Ratzel, CPC-A Wooster OHSuzanne Fedelia, CPC-A Youngstown OHPamela Davis, CPC-A Broken Arrow OKJulie McKeague, CPC-A Broken Arrow OKTara BigEagle, CPC-A Lenapah OKAngela Blaylock, CPC-A Nowata OKTraci Gearhart, CPC-A Nowata OKSherie Herrera, CPC-A Nowata OKDelora Tunison, CPC-A Nowata OKJanet Winslow, CPC-A Nowata OKVicki-Lee Mary Lucas, CPC-A Gresham ORPatricia Treski, CPC-A Salem ORDavid C Woody, Jr, CPC-A Tigard ORDoreen L Dale, CPC-A Bristol PACarrie Delone, CPC-A Camp Hill PADorothy Majewski, CPC-A Douglassville PAMary Theresa Romaguera, CPC-A Ephrata PAZelfa DeRose, CPC-A Harrisburg PA
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Roger Dale Rayburn, CPC-A Clarksville TNCatherine M VanBrunt, CPC-A Clarksville TNPatricia K Wilson, CPC-A Clarksville TNApril Kolwyck, CPC-A Dyersburg TNDorothy Lonnie Gardner, CPC-A Gray TNRegina L Jones, CPC-A Gray TNDinah Lynn Martin, CPC-A Jackson TNNancy L Wyatt, CPC-A Johnson City TNCharlotte R Williams, CPC-A Jonesborough TNLeigh Ellen Harris, CPC-A Knoxville TNTammy Mowery, CPC-A Knoxville TNSharon E Moyers, CPC-A Knoxville TNKirthi Kay Rangnekar, CPC-A Knoxville TNDeborah A Adolph, CPC-A Memphis TNLucretia S Gardner, CPC-A Nashville TNLana Hudson Woodcock, CPC-A Pleasant Shade TNMegan Kenner, CPC-A Seymour TNVirginia Lee Buddie, CPC-A Wildersville TNTila Lynn Broadway, CPC-A Baytown TXJoAnn Brant, CPC-A El Paso TXPriscilla Figueroa, CPC-A El Paso TXTracie Telford, CPC-A El Paso TX
Donna Canady, CPC-A Granbury TXMiranda R Joseph, CPC-A Houston TXDeborah Lee Ferguson, CPC-A Live Oak TXAyesha Khurram, CPC-A Plano TXJoanna Lira, CPC-A San Elizario TXNoelle E Anderson, CPC-A Spring TXRose Guthrie, CPC-A North Ogden UTLori McLeish, CPC-A South Jordan UTKassi Whittaker, CPC-A South Jordan UTMichelle Higginson, CPC-A St. George UTKaren Aquilano, CPC-A Stafford VAMelissa Bailey, CPC-A Wytheville VADwina Maria Medina Warren, CPC-A Pittsfield VTDaryl L Donahue, CPC-A Randolph VTMarianne Slack, CPC-A Randolph VTBarbara P Conant, CPC-A Randolph Center VTSusan Ann Kaikala, CPC-A Lake Stevens WACathleen E Mesquita, CPC-A Stanwood WAJennifer Dixon, CPC-A Omro WIAaron Lambert, CPC-A Beckley WVAmanda Copley, CPC-A Fort Gay WV
Stephanie M Browning, CPC-H-A Hedgesville WVBrandy Sanders, CPC-A Kenova WV
Catherine Lowery, CEDC Mobile AL
Jeanette M Kirby, CPC, CFPC Windsor CA
Lisa M Weston, CPC-H, CASCC Fellsmere FL
Kelley B Kirkland, CPC, CEDC Jacksonville FL
Nancy Ann Henry, CPC-A, CEDC Cross Plains IN
Jennifer L Hickey, CPC, CIMC Burlington MA
Erin E Clifford, CPC, CENTC Springfield MA
Betsy Marie Lewis,
CPC, CASCC Pasadena MD
Elizabeth W Baity, CPC, CPRC Yadkinville NC
Theresa Von Hoene, CPEDC Cincinnati OH
Anastasia Zaharioudakis, CPC, CASCC Wyomissing PA
Martha Nel, COSC Germantown TN
Sumalee A Bell, CPC, CPC-H, CDERC, CGIC Houston TX
Rose Moore, CPC, CPC-I, CEMC Chesterfield VA
Tammy Shepherd Moore, CPC, CFPC Vinton VA
Christine P Denis, CPC, CUC Colchester VT
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40 AAPC Coding Edge
feature
Readers wrote Coding Edge with questions concerning coding rules for consultation services 99241-99245, 99251-99255 (see “Consult or Not? Here’s How to Know for Sure,” May 2009 and “Coding Consultations When Components or Time is a Factor,” June 2009).
Can a Consult Be Incident To?Kansas City Chapter member Patti Frank, CPC, asks, “I understand that a consultation cannot be a shared/split service. But can a consultation be billed incident to the collaborating physician, or must a consultation always be billed under the NPP’s own number? Please address both Medicare and commercial payers.”
For commercial payers, the honest response is, “We can’t tell you.”
Rules governing non-physician practitioner (NPP) bill-ing services for commercial payers depend on the indi-vidual payer and its contract with the provider or facility. Because these arrangements frequently are proprietary, the only way to know the rules for sure is to check your contract or otherwise inquire with the payer.
For Medicare, NPPs acting within scope-of-practice may bill consultation services under their own provider num-bers—provided all service requirements have been met and documented. NPPs should not report consultation services under a physician’s provider number or incident to physician services.
This answer is not as simple as it seems.
According to the Medicare Benefit Policy Manual, chapter 15, section 60.2 (www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf), an NPP “may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medi-care as a physician assistant’s or nurse practitioner’s service.”
In other words, Medicare will allow an NPP, acting within scope-of-practice in her state, to report consulta-tion services under her own provider number in either the inpatient or outpatient setting. For this to happen, how-ever, a number of conditions must be met:
The NPP must be able to provide the full range of service expected by the requesting source.
“The entire justification for a consult is that the con-sulting provider’s knowledge goes beyond that of the requesting provider,” notes Jill Young, CPC, CEDC,
CIMC, president of Young Medical Consulting, LLC, and vice chair of the AAPC Chapter Association. “Ideally, the medical record will substantiate that the NPP has relevant expertise to provide the consult. For instance, an NPP providing a cardiology consult might note that she is certified in the area, or has 20 years experience work-ing in that field.”
The service must be requested of the billing NPP specifically. That is, if the consultation is requested of a physician, an NPP cannot “take the place of” the requested physician in providing the service.
In the inpatient setting, the NPP must have con-sulting privileges with the hospital or facility.
“Hospitals offer different kinds of privileges—admission privileges, procedure privileges, and so on,” Young stresses. “An NPP cannot report an inpatient consultation if she doesn’t have consulting privileges with the indi-vidual facility.”
The same medical necessity and documentation requirements for evaluation and management (E/M) services apply to NPPs as to physicians.
Remember, consultation services cannot be shared. If an NPP confers with a physician at all, the service is deemed shared or split and may not be billed as a consultation.
For Medicare, payment for NPP services is 85 percent of the allowable fee schedule amount. In contrast, reporting services incident to a physician’s services allows the NPP to bill under a supervising physician’s provider number, which provides 100 percent reimbursement of the fee schedule amount.
Incident to guidelines do not apply in the hospital set-ting. The Medicare Claims Processing Manual, chapter 12, section 30.6.13.E, states flatly, “‘Incident to’ E/M visits, provided in a facility setting, are not payable under the Physician Fee Schedule for Medicare Part B.”
In an office setting, incident to payment for Part B ser-vices applies when the incident to criteria, as described by the Medicare Benefit Policy Manual, chapter 15, sections 60.1-60.3, have been met. Among other requirements, these guidelines specify, “a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and manage-ment of the course of treatment” (60.1.B).
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Expel Consultation Code WorriesSubstantiate incident to and transfer of care claims.
By G. John Verhovshek, MA, CPC
www.aapc.com August 2009 41
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Section 60.2 of the same document further explains:
“A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service cov-ered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. As explained in §60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, profes-sional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physi-cian’s continuing active participation in and management of the course of treatment.”
The requirement that a physician provide an initial ser-vice means that an NPP could not report an incident to consultation. If the physician has met with the patient and initiated a course of treatment, there is no medical necessity for a subsequent NPP consultation.
“The NPP may provide services subsequent to the physi-cian’s initial meeting with the patient, and these services may be incident to, but an NPP would not provide the initial consultation or other initial service incident to,” Young confirms.
Not Every Referral Means a ConsultAnother reader wanted to confirm the importance of the requesting physician’s intent in determining if a consul-tation services may be reported. She expressed frustra-tion that her physician treats as a consult every patient referred to him by another physician.
The first question to consider when deciding if a medi-cally-necessary service may be classified as a consultation is, “Was the referring physician asking for an opinion or advice so he could continue to treat the patient?” If not, the service can’t be a consult, regardless of whatever documentation requirements the service might meet.
The Medicare Claims Processing Manual, chapter 12, sec-tion 30.6.10.B (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) states, “A transfer of care occurs when a physician or qualified NPP requests that another physi-cian or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.”
“When this transfer is arranged, the requesting physi-cian or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her ser-vice, in the patient’s medical record or plan of care.”
When a transfer of care occurs, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed, rather than a con-sultation.
For example, an emergency room (ER) physician treats a patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. In this case, the orthopedist would not report a consulta-tion service because advice or opinion is not required by the ER physician.
If there’s any doubt as to the referring/requesting physi-cian’s intent for sending the patient, seek clarification. The consulting physician should be careful to document the service precisely. For instance, the procedure note might begin, “I am seeing [patient] today at the request of [referring physician] who has asked I evaluate the patient in consultation for [condition and/or signs and symptoms] and recommend treatment so that [referring physician] may continue to care for [patient]. Based on findings: [list findings]; I recommend: [list treatment options, etc.].” Such a statement substantiates the consul-tation request, reason, and report, and readily identifies the service’s true intent.
As always, the standard components of an E/M service (history, exam, medical decision-making, time, etc.) must be performed and documented appropriately for the level of service reported.
G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.[ ]
“Hospitals offer different kinds of privileges—admission privileges, procedure privileges, and so on,” Young stresses. “An NPP cannot report an inpatient consultation if she doesn’t have consulting privileges with the individual facility.”
42 AAPC Coding Edge
facility
The grading of hospitals and physicians is a new industry, and one the public is taking a keen interest in when deciding from whom to get care and where to go. Complete documentation and proper coding not only ensure proper reimbursement; they reflect quality of care in an increasingly consumer-driven market. With this in mind, providers and facilities alike should be on the lookout for these top five coding mistakes when reporting Medicare Part B services in the Part A setting.
1. UndercodingMedical schools provide little formal cur-ricula in evaluation and management (E/M) coding, and providers often have limited knowledge of the topic. In a pri-mary care clinic setting, family practice, or internal medicine, residents may learn they can bill lower-level services (such as 99201-99203 inpatient, or 99211-99213 outpatient) without seeking a teaching phy-sician’s supervision. They’re never taught to apply higher-level codes (for example, 99204-99205 inpatient and 99214-99215 outpatient), or the specific requirements of the 1995 or 1997 E/M documentation guidelines.
It’s no wonder so many internal medicine
and family practice physicians bill inordi-nate numbers of low-to-mid-level E/M ser-vices, robbing themselves of revenue.
Historically, payers have contacted providers whose claims have fallen out of line with expected coding patterns. Providers receive letters informing them that they are billing too many codes of a particular level (as com-pared to their peers), but the letter provides no information on correct coding principles. The provider might become alarmed, and begin to downcode to avoid questions. This “solution” promotes a false sense of security, has a negative effect on coding patterns and reimbursement, and tempts compliance problems down the line.
When providers undercode, they paint a picture of decreased patient care. Payers judge the level of care according to the codes they receive. For instance, if a provider bills 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examina-tion; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of low to moderate severity. Physi-cians typically spend 15 minutes face-to-face with the patient and/or family for every patient, even if a patient has five co-morbidities, the payer may believe the patients are receiving inadequate attention.
CMS stated in the 2008 Inpatient Prospec-tive Payment System (IPPS) Final Rule (Federal Register, Vol. 73, No. 161, Aug. 19, 2008, “Rules & Regulations,” p.48448). “We do not believe there is anything inap-propriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare pay-ment as long as the coding is fully and properly supported by documentation in the medical record.”
For instance, don’t just settle for 250.00 Diabetes mellitus without mention of complica-tion, type II or unspecified type, not stated as uncontrolled when there is a more accurate and specific code choice, such as 250.21 Diabetes with hyperosmolarity, type II or unspec-ified type, not stated as uncontrolled or 250.23 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled.
Do not be intimidated: If your patient popu-lation is sick enough and your documentation and coding reflects the level of services you provide, don’t be afraid to bill correctly.
Part B E/M in a Part A Setting
By Jules Enatsky, RT, BSN, CPC-H
Five common mistakes can hobble physician coding in a facility.
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www.aapc.com August 2009 43
facility
Providers should be certain they are docu-menting and coding based on one of the two accepted E/M guidelines, American Medical Association (AMA) 1995 or the Centers for Medicare & Medicaid Services (CMS) 1997. They also may consider an independent audit of their documentation and coding practices.
2. Illegible DocumentationAs the old saying in medicine goes, “If you cannot read it, you didn’t do it.”
In the inpatient setting, many hospitals are requesting providers with less-than-stellar penmanship to re-document or amend notes so they are legible. This became especially important when, in October 2008, Medi-care changed to medical severity diagnostic related groups (MS-DRGs), allowing hos-pitals reimbursement for severity and com-plexity of care as reflected by documented ICD-9-CM codes.
Many institutions have put special programs in place, where medical records are concur-rently reviewed by a clinical documenta-tion specialist (usually a registered nurse) to assist providers in identifying the most relevant illnesses based on physician docu-mentation. This process potentially leads to increased reimbursement for the hospital and providers.
Institutions initiating such programs have seen phenomenal increases in their case mix index (CMI). Individual providers also have enjoyed the benefit of improved communi-cation with hospital utilization and coding staff, and their own coding staff.
3. EHR ReluctanceThe use of electronic health records (EHRs) in the inpatient setting has brought a new level of sophistication to providers’ documentation. More and more groups and single practice providers are moving to EHR; comparatively speaking most provid-ers still do not use EHR. And in those insti-tutions that have switched from paper to EHR, many of the providers do not use an EHR in their offices. Unless an institution mandates in-house EHR adoption, many
physicians are delaying it for as long as pos-sible due to cost, difficulty of transition, and time taken away from patients.
EHR implementation is inevitable, how-ever. Providers have only until 2015 to have EHRs in their practices. To assist physicians with EHR adoption, the government is providing incentives up to $44,000. Provid-ers should also consider piggy-backing on a hospital EHR, possibly obtaining a reduced fair-market purchase price, and easing com-munication between provider and hospital.
Recommendation: For practices with three or more providers, have the office staff learn the EHR system first, so they can become profi-cient and assist the physicians down the road.
4. The Missing Chief ComplaintOne common problem with provider docu-mentation may be corrected with the adop-tion of EHR: The missing chief complaint.
Providers often begin their subsequent notes with symptoms the patient may not have, or a comment pertaining to the patient’s status in relation to a procedure or medica-tion, without mentioning why the patient is being treated.
This shortcoming is especially pressing when multiple providers of different special-ties treat the same patient. For example, if an admitting physician and one or two consulting providers all bill subsequent inpatient care using the same principal diagnosis, only the provider who gets his claim to the payer first will be paid. The others most likely will be denied as dupli-cate services.
Multiple treating providers should bill ser-vices with the principle diagnosis of their specialty. For example, a patient is admitted with an acute myocardial infarction (AMI), a history of diabetes mellitus Type II (DM II), chronic obstructive pulmonary disease (COPD), and gastro esophageal reflux dis-ease (GERD), with a cardiologist as the phy-sician of record. The patient also is followed by the primary care provider (PCP), who manages the patient’s DM II and GERD. A
pulmonologist manages the COPD. In this case, the admitting cardiologist would bill using the AMI as the principal diagnosis.
On subsequent visits, the cardiologist would continue to code the AMI as the principal diagnosis (along with any newly-diagnosed cardiac illness), the PCP would continue to code the DM II and GERD, and the pulmonologist would continue to code the COPD.
Providers must carve out the patient treat-ment pie according to their specialty. This can become tricky, especially when hospital-ists are involved in treating the patient, or when the PCP is still involved and has not yet relinquished care of the patient.
5. Not Reporting a Provisional DiagnosisMost physicians do not realize CMS pays hospitals and providers for working up patients’ illnesses in the Part A setting. Phy-sicians-in-training learn to pick all the diag-nosis that may apply to a patient, and then work through them one by one until finding the right one(s). This is not the case in the office or outpatient setting: Provisional or “rule out” (R/O) diagnoses are not permitted for coding purposes in outpatient records.
The problem for hospitals is that they must depend on physician documentation to support the degree of care provided. As previously mentioned, many hospitals have developed Clinical Documentation Improvement Programs (CDIPs) to review records concurrently, and to capture the acute severity of care data. This method reduces the number of queries hospital information management (HIM) coders must produce to get to the heart of patient diagnosis coding.
“We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record.”—CMS
Jules Enatsky, RT, BSN, CPC-H, is senior consultant with JA Thomas & Associates. He has over 30 years of combined expe-rience in radiology technology, acute care nursing, and consult-
ing for Part B hospitals and physicians.
44 AAPC Coding Edge
A 24-year-old roofer fell 12 feet from a one-story rooftop onto a tree and was impaled by a tree branch in his left flank at the level of the umbilicus. The patient was resuscitated in the emergency department (ED) with crystalloids, which were administered through two large-bore venous catheters. He was transferred to the operat-ing room conscious and supine. Extreme care was taken to avoid manipulating the branch, and rapid-sequence intubation was used to gain control of his airway. The abdominal cavity was explored through a vertical midline incision. During the operation, bile-stained fluid was encoun-tered in the right upper quadrant of the patient’s abdomen and the lateral aspect of the second portion of the duodenum was found to be perforated. The gallbladder, pancreas, liver, and inferior vena cava were negative for injury. The tree branch was removed under direct vision after the extent of the patient’s injuries was assessed. A Kocher maneuver was used to mobi-lize the patient’s duodenum and the injury was repaired with transverse closure in two layers. A distal feeding jejunostomy tube was placed. The entrance wound was debrided of dirt and splinters, lavaged, and allowed to heal by secondary intention.Solution: Documentation is scant, so we can only infer a proper evaluation and management code category. There’s no evidence to support critical care (99291-99292). Rather, the patient was treated in the ED and, presumably, admitted for surgery. CPT® guidelines state, “When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service… all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.”In other words, you may report only the inpatient admission (99221-99223), not the admission and ED service (99281-99285). Because surgery was performed on the same day
as admission, append modifier 57 Decision for surgery to the applicable code 99221-99223. Emergency intubation is reported with 31500 Intubation, endo-tracheal, emergency procedure, while resuscitation is reported with 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest). Documentation is patchy for these services, however.The primary procedure involves removal of the tree branch from the patient’s duodenum. Code 44010 Duodenotomy, for exploration, biopsy(s), or foreign body removal is a tempting choice; but a better code would be 44602 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation. Whereas 44010 describes incision to remove an intra-luminal foreign body (that is, a foreign body within the duodenum), 44602 specifically describes repair for “wound, injury or rupture,” with removal of the tree branch as incidental to the repair. The latter code is more fitting based on the available documentation. Although payment alone should never drive code selection, 44602 reim-burses nearly 60 percent more than 44010.The appropriate code for J-tube placement is add-on code +44015 Tube or needle catheter jejunostomy for enteral ali-mentation, intraoperative, any method. There are no bundling issues with +44015 and 44602 (or 44010).Report debridement of the wound using 11040-11044, as appro-priate (depth is not clearly indicated in the documentation).The primary diagnosis is identified easily as 863.31 Injury of duodenum with open wound into cavity. Any number of E codes—for external causes of injury—may be cited, including E849.3 Place of occurrence industrial place and premises (eg, building under construction), E882 Fall from or out of build-ing or other structure, E888.0 Fall resulting in striking against sharp object, and, E920.8 Accident caused by other specified cutting and piercing instruments or objects.
The Case of the Impaled RooferSee “Extreme Coding,” June 2009 Coding Edge, for the complete note.
www.aapc.com August 2009 45
A 35-year-old worker was hit by a heavy object while working in a fa
ctory. Upon
arrival in the ED, the patient’s Glasgow Coma Scale was 15/15, blood
pressure was
stable (120/80 mm Hg) and pulse rate was 86 beats/min. Physical exam
ination revealed
multiple rib fractures in the left half of the thorax, abdominal bre
athing and a
right flail chest, macroscopic hematuria, and swelling of the left a
bdominal wall.
Chest examination disclosed reduction in breathing sounds on the lef
t side. Left
upper quadrant abdominal tenderness was evident.
A left-sided hemothorax was treated by tube thoracostomy, which drai
ned 500 ml of
blood initially and 200 ml in the next 30 minutes before surgical ex
ploration was
performed. Serial hematocrit ranged between 39–33 percent over a one
hour interval.
Chest X-ray showed massive left hemothorax without any additional si
gns to suggest
diaphragmatic injury.
When hemorrhagic shock developed (a rapid pulse rate increase to 120
to 130 beats/
min and blood pressure decrease to 90/50 mm Hg), immediate surgical
exploration was
performed before further radiological examinations. During surgery,
through a midline
umbilical abdominal exposure, the right kidney and liver appeared no
rmal, but the
left kidney and spleen were not found in their anatomical position.
The left hemidi-
aphragm had a 10 cm oblique posterior tear. The left kidney was foun
d lacerated in
the left chest, separated completely from its vascular tree.
The renal vessels, the left ureter and renal pelvis were easily iden
tified and
ligated separately. The stump of the renal artery did not bleed activ
ely at the time
of surgery. The splenic artery and the short gastric arteries were l
igated also. The
lacerated diaphragm was sutured by single layer non-absorbable sutur
es. An abdominal
tube was placed in the left retroperitoneum at the anatomic place of
the left kidney
to monitor possible bleeding.
The patient remained in the intensive care unit for the next 10 days
, and was dis-
charged on postoperative day 21.
An Extreme Case of Workers’ Comp
Can You Code This Note?
Traumatic rupture of the diaphragm, especially during motor vehicle accidents, is not uncommon. In most cases, such injury is associated with vascular and visceral injuries. In this case, blunt trauma by lateral impact distorted the patient’s chest wall, shearing the diaphragm. The patient
presented with gross hematuria, possibly because of the renal laceration, and a diagnosis of diaphragmatic disrup-tion occurred during investigation for suspected renal injury. Can you code this?
extreme coding
Have You Gone to Extremes?
Have you got a challenging scenario you’d like to see discussed in this forum? Send your op report to [email protected]. Before forwarding it to us, please safeguard the patient’s personal information by changing dates and removing unique identifiers.
46 AAPC Coding Edge
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Coding moderate sedation (or conscious sedation) and monitored anesthesia care (MAC) is not difficult;
however, distinguishing what the services provided are and deciphering conflicted information about which phy-sicians can report what codes can be confusing.
Misinterpretation Clouds Payer JudgmentHistory and changing terminology play a role in the con-fusion. Until the mid-1980s, anesthesiologists classified anesthesia into three types: general, regional, and local standby. Some payers, however, interpreted “standby” in the literal sense—mistakenly thinking the anesthesiolo-gist was “standing by” and not providing a service—and would not pay for local standby services.
To clear up the confusion, the American Society of Anesthesiologists (ASA) replaced the term “standby” anesthesia with “monitored anesthesia care,” approving its first position statement on MAC in 1986. Both the new term and position statement demonstrated active involvement in patient care. In 1998, the MAC position statement was revised (www.asahq.org/Newsletters/1998/12_98/ASAupdates_1298.html) and the concept of a sedation continuum as illustrated by L. Charles Novak, M.D. became part of ASA’s efforts to educate non-anesthesiologists about conscious sedation (Cohen/McMichael, 2004 www.asahq.org/Newsletters/2004/06_04/whatsNew06_04.html). The MAC position statement was last updated Sept. 2, 2008.
MAC vs. Conscious SedationMAC services are rendered by anesthesia providers who aren’t involved in the diagnostic or procedural service, and include the same care as any other anesthesia service: a pre-anesthesia assessment, documentation of vital signs during the procedure, and post anesthesia patient care. If necessary, the anesthesia provider must convert to a gen-eral anesthetic, which requires anesthesia training.
In contrast, moderate (conscious) sedation, as defined by the CPT®, closely matches the ASA’s definition of a drug induced depression of consciousness (see sidebar). CPT® further indicates that moderate sedation does not include the MAC codes (00100-01999) found in the anesthesia section of the CPT® book.
Moderate sedation codes 99143-99145 require the seda-tion service be provided by the same physician perform-ing the diagnostic or therapeutic service, along with an independent trained observer to assist in monitoring the patient. Codes 99148-99150 require the sedation service be provided by a physician other than the one performing the diagnostic or therapeutic codes, but an independent trained observer is not required. There are additional CPT® instructions for services performed in a facility or non-facility setting, as well as exclusions for codes listed in Appendix G of the CPT® book.
Although a coder may expect that anesthesia codes are only reported by trained anesthesia providers, existing insurance policies indicate non-anesthesia providers will be reimbursed when billing the appropriate anesthe-sia codes. The billing physician, however, must report anesthesia time in minutes and meet the requirements for MAC as defined by the ASA. An anesthesia modi-fier (G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure, G9 Monitored anesthesia care for a patient who has a history of severe cardio-pulmonary condition, or QS Monitored anesthesia care service) identifying the service must also be appended. See Oxford Health Plans (March 1) Medical and Administrative Policies (Moderate (Conscious) Sedation and Monitored Anesthesia Care (MAC), (www.oxhp.com/secure/policy/moderate_sedation_309.html) for more information.
Several Medicare Administrative Contractors (also known as MACs), formerly known as fiscal intermediaries, have published Local Coverage Determinations (LCD) related
Knowing where the line is can clear up hazy anesthesia reporting.
By Kelly Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN
EXPE
RT
Draw a Line Between
Moderate (Conscious) Sedation
and Monitored Anesthesia Care
www.aapc.com August 2009 47
feature
to MAC services. Statistical anesthesia modifiers are required to track MAC cases. Since 1992, all Medicare contractors require the anesthesia modifier QS, and LCD’s will identify those carriers that require G8 and G9. Usually, it isn’t necessary to report both modifier QS and either modifier G8 or modifier G9 (as applicable to the patient) because each of these anesthesia modi-fiers indicate MAC was used during the procedure. If the procedure converts from a MAC to general anesthesia, no modifier is necessary.
In a 1991 report (www.oig.hhs.gov/oei/reports/oei-02-89-00050.pdf), Richard P. Kusserow of the Office of Inspector General (OIG) indicated that a carrier private business plan identified over 700 procedures for which the services of an anesthetist customarily are not required. Anesthesia claims for those procedures may be denied unless documentation is provided to support the medical necessity for an anesthetist (defined in this report as anesthesia services are rendered by anesthesiologists, other qualified physicians, certified registered nurse anesthetists (CRNAs), and anesthesiologist assistants (AAs)). Coders must understand the reported and billed service, and ensure documentation supports the reported service, whether it is moderate sedation or MAC. It is also important to follow Medicare LCD and medical necessity guidelines for any procedure performed.
American Society of Anesthesiologists (ASA) Definitions
Monitored anesthesia care and moderate sedation are clinically distinct services. Here’s how the ASA defines each:
Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interven-tions are required to maintain a patent airway, and spontane-ous ventilation is adequate. Cardiovascular function is usually maintained.
Note: Reflex withdrawal from a painful stimulus is NOT con-sidered a purposeful response.
Monitored anesthesia care (MAC) is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the proce-dure, the patient’s clinical condition and/or the potential need to convert to a general or regional anesthetic.
MAC includes all aspects of anesthesia care: a pre-procedure visit, intra-procedure care, and post-procedure anesthesia management. During monitored anesthesia care, the anesthe-siologist provides or medically directs a number of specific services, including but not limited to:
Diagnosis and treatment of clinical problems that occur during the procedure
Support of vital functions
Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary for patient safety
Psychological support and physical comfort
Provision of other medical services as needed to complete the procedure safely
MAC may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instru-mentation is required.
MAC is a physician service provided to an individual patient. It should be subject to the same level of payment as general or regional anesthesia. Accordingly, the ASA Relative Value Guide® provides for the use of proper base procedural units, time units and modifier units as the basis for determining payment.
To see the ASA’s anesthesia’s definitions online, go to www.asahq.org/publicationsAndServices/standards/20.pdf and www.asahq.org/publicationsAndServices/standards/35.pdf.Kelly Dennis, MBA, CPC, CPC-I CANPC, ACS-AN
Coding Edge–sidebar
Although a coder may expect that anesthesia codes are only reported by trained anesthesia providers, existing insurance policies indicate non-anesthesia providers will be reimbursed when billing the appropriate anesthesia codes.
Kelly Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, has over 26 years experience in anesthesia bill-ing. She serves as lead anesthesia advisor for the Board of Medical Specialty Coding and is an active member of several associations, includ-ing past legislative liaison and past president of Florida Anesthesia Administrators’ Association, past-president of Medical Group Management
Association’s Anesthesia Administrators Assembly and a member of AAPC since 2000. She is president of Perfect Office Solutions, Inc.
48 AAPC Coding Edge
�featured coder
Moderate (conscious) sedation/analgesia (CPT® 99143-99150) is a drug-induced depression of consciousness during which the patient responds purposefully to verbal command, either alone or accompanied by light tactile stimulation. No interventions are necessary to maintain a patent airway—spontaneous ventilation is adequate and cardiovascular function is usually main-tained—so the degree of risk is less.
Code According to RequirementsModerate sedation codes are age and time specific. Codes 99143-99145 identify seda-tion provided by a physician who also per-forms the primary procedure.
99143 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requir-ing the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physi-ological status; younger than 5 years of age, first 30 minutes intra-service time
99144 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requir-ing the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physi-ological status; age 5 years or older, first 30 minutes intra-service time
+99145 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requir-ing the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physi-ological status; each additional 15 minutes intra-service time (List separately in addi-tion to code for primary service)
A physician may choose to deliver moderate sedation for services not usually performed in the operating room (OR), but which are too invasive for the patient to tolerate with no sedation at all. An example is a simple closure of a 2 cm lip laceration on a healthy, 60-year-old patient. A physician who pro-vides both the procedure and the moderate sedation would report 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less, along with 99144 for the first 30 minutes of con-scious sedation and, if necessary, one unit of 99145 for each additional 15 minutes.
When the primary physician provides moderate sedation, an independent, trained observer must be on hand to help monitor the patient. Documentation should provide proof of the observer’s presence and note that the observer monitored the patient’s cardiorespiratory functions (pulse oximetry, electrocardiogram (EKG), and respiratory monitoring and blood pressure) for the dura-tion of the moderate sedation.
Codes 99148-99150 identify sedation pro-vided by a physician who does not perform the primary procedure.
99148 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes of intra-service time
99149 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time
+99150 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the healthcare professional performing
the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time (list separately in addition to code for primary service).
For instance, consider the above example, except in this case, the patient has co-morbidities (eg, cardiac, respiratory, neuro-logical) that put him at a higher risk and prompt the surgeon to use another physi-cian to administer the sedation service. The surgeon would report 12011. The physician providing the moderate sedation would report 99149 and +99150, as appropriate to the time of the service.
About time: Moderate sedation codes are reported according to intra-service time, which starts with the administration of the sedation agent(s) and ends when personal contact by the sedating physician concludes. See the CPT® manual for a list of services considered integral to moderate sedation, as well as a services that may count toward intra-service time.
Look Out for Bundled ServicesCPT® Appendix G lists codes with moder-ate sedation bundled (included) in the reim-bursement allowed for the procedure. Codes in Appendix G also appear throughout the CPT® manual with a “bull’s-eye” () next to them. The Centers for Medicare & Med-icaid Services (CMS) instructs, “The physi-cian can bill the conscious sedation code as long as the procedure with which it is billed is not listed in Appendix G of CPT” (see www.cms.hhs.gov/Transmittals/downloads/R1324CP.pdf).
Exceptions can occur: CPT® allows sepa-rate reporting of 99148-99150 for moderate sedation during a “targeted” procedure, if:
1. A second physician (not the physician providing the supporting moderate sedation service) provides the moderate sedation; and
Reduce Risk of Poor Moderate Sedation ChoicesLet age and time determine the codes.By Samantha Mullins, CPC, CPC-I, ASC-AN, MCS-P
www.aapc.com August 2009 49
2. The moderate sedation and targeted procedure that prompts the moderate sedation occur in a facility setting.
No Anesthesiologist RequiredGenerally, a physician—not an anesthesiol-ogist–administers conscious sedation. The only time an anesthesiologist should bill for moderate sedation (99143-99150) and not an anesthesia service (00100-01999) is when he is also the surgeon for the case. CMS provides the following example (see www.cms.hhs.gov/Transmittals/downloads/R1324CP.pdf):
“If the anesthesiologist or CRNA [certified registered nurse anesthetist] provides anes-thesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT® code 01991. The service must meet the criteria for moni-tored anesthesia care. If the anesthesiolo-
gist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious seda-tion code and the injection or block. How-ever, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.”
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If this is your mindset, we see you as a major asset. You’ll fit right in with our top-notch team. You’ll thriveunder management that will challenge you to go beyond your abilities – by cross-training you to become proficient at coding for various departments.
Not only can this job live up to your expectations, so will our hospital. UNM Hospitals is a highly advanced, paperless environment, allowing coders to thrive through access to the most current technology. What’s more,UNMH strives to code paperwork and billing in real time, before patients are even discharged. Which is whywe’re looking for someone as efficient as you.
As New Mexico’s only Level I trauma hospital, UNM Hospitals creates opportunities to use the latest technologies and because we’re a teaching hospital, you’ll find all the resources to succeed.
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Samantha S. Mullins, CPC, CPC-I, ASC-AN, MCS-P is coding manager for DST Health Solu-tions in Birmingham, Ala. (http://dsthealthsolutions.com/). She has a passion for anesthesia coding with experience in pedi-atrics, surgery, and emergency medicine and has directed
coding, compliance, billing, practice management, and managed care. Mullins has sat on the BMSC’s Anesthesia Specialty Advisory Board since 2005 and is a member of the MGMA and MGMA focus groups. She is a PMCC instructor and has served as Birmingham Chapter’s 2003 President-elect and 2004 President.
Sedation Comes in Several LevelsModerate sedation is just one of several sedation levels. There is also deep sedation, minimal sedation, and monitored anesthesia care (MAC).
Deep sedation/analgesia (CPT® 00100-01999) is a drug-induced depression of consciousness during which the patient cannot be easily aroused but responds purposefully following repeated or painful stimulation. Independent ventilatory function may be impaired. The patient may require assistance to maintain a patent airway. Cardiovascular function is usually maintained.
Any deeply sedated patient has a larger risk factor; sedation levels can deepen unintentionally depending on a patient’s co-morbidities, the medications admin-istered, and the dosage and administration route. Thus only qualified anesthesia providers (anesthesi-ologists, CRNA, Anesthesia Assistant (AA)) should purposely induce deep sedation.
Minimal sedation (anxiolysis) is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected. This level of anesthesia is bundled into medical procedures and not separately billable.
Monitored Anesthesia Care. Learn about MAC in the article “Draw a Line Between Moderate (Con-scious) Sedation and Monitored Anesthesia Care” on page 46 in this issue.
Samantha S. Mullins, CPC, CPC-I, ASC-AN, MCS-P
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