january 2014 jean c. russell, ms, rhit [email protected]@epochhealth.com richard...
TRANSCRIPT
January 2014
Jean C. Russell, MS, RHIT [email protected]
Richard Cooley, BA, CCS [email protected]
Matthew H. Lawney MSPT, MBA, CHC, [email protected]
518-430-1144
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Agenda• Visit Codes (E/M Services)
• ED E/M Changes• Clinic E/M Changes
• Professional/Technical Implications• Pricing Implications
• Observation Changes• Proposed changes for Provider-Based
Reporting• Incident to Guideline Changes
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Proposed ChangesCMS proposed to replace the current five ED E/M
visits for type A and type B ED with a single one for each type99281-99285G0380-G0384This proposal was NOT accepted in the final rule
CMS also proposed to replace the current ten technical clinic E/M visits with a single codeThis proposal WAS adopted
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ED E/M ProposalCMS did not adopt a single G code for reporting ED
E/MCommenters felt the range of services provided in the ED
varies too significantly to reduce all visits to the single level
CMS decided to not make any changesThey are continuing to investigate
No change to the codesNo change to split billingNo change to requirements for technical E/M guidelines
for the ED
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Clinic Visit E/M CodesNew Clinic E/M
99201 – New Pt Lvl 199202 – New Pt Lvl 299203 – New Pt Lvl 399204 – New Pt Lvl 499205 – New Pt Lvl 5
Established Clinic E/M
99211 – Est Pt Lvl 199212 – Est Pt Lvl 299213 – Est Pt Lvl 399214 – Est Pt Lvl 499215 – Est Pt Lvl 5
Primary service performed and reported in a clinic is a medical visit
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E/M Clinic Visit Split BillingMedicare expects visits to a hospital based clinic
with a hospital based “physician” to be split billedPrior to January 1, 2013, hospitals would report
an E/M professionally based on CMS/CPT guidelines (either 1995 or 1997)
And an E/M technically based on hospital developed technical clinic E/M guidelines
Professional Bill (POS 22)99214
Technical Bill99212
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Clinic E/M ChangeEffective January 1, 2014 there is only one code
reported technically for clinic visits to a hospital-based clinic:G0463 - Hospital outpatient clinic visit for
assessment and management of a patientThis code replaces all of the clinic E/M codes
reported technically (99201-99205 and 99211-99215)
No change to the professional reporting rules and codes
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Summary of the Clinic Change
All clinic visits billed technically to Medicare will be reported with the same code (G0463) regardless of the complexity / duration of the visit
Beneficiary co-payment for technical component alone is close to $40 (national unadjusted); 40% of the total
There is no longer a differentiation technically between “new” and “established” patient reported codes
The professional clinic E/M’s have not changed
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Impact of the Clinic ChangeCMS has acknowledged the challenges faced by
hospital for developing guidelines for determining the appropriate visit levelNo longer necessary to develop Medicare
technical clinic E/M guidelinesED guidelines are still required
Other payers (e.g., Medicaid DOH and OMH) that are billed technically will expect the 99201-99215 codes until we are notified otherwise
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Charging SuggestionsSuggest hospitals keep the usual ten clinic E/M levels
with their charges varying by clinic E/M (i.e., 99201-99205 and 99211-99215) and then map these variable charges to the single G0463 for Medicare and (most likely) Medicare HMOsCharges may not be greater than Medicare APC
payment for the lower level visits (e.g., 99211)Should all payers be charged the same?
Issue – Medicare has a claim suspension edit in some cases when payment exceeds submitted charges
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Telephone/Internet Assessment and Management
New E/M codes for 2014Not paid under OPPS or under MPFS99446, Inter-professional telephone/Internet
assessment/management service provided by a consultative physician includes verbal and written report to the patient's treating/requesting physician; 5-10 minutes of medical consultative discussion/ review99447 … 11-20 minutes99448 … 21-30 minutes99449 … 31 minutes or more
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Telephone/Internet Assessment and Management
Used when face-to-face contract may not be timely or feasible
Not used when the patient has been transferred to the consulting doctor before the assessment
May include review of medical records, diagnostic tests, …
Majority of the service time (more than 50%) must be devoted to the actual verbal/internet discussion
Single code for cumulative timeRequest for consult must be documented
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Hypothermia Tx 99481, Total body systemic hypothermia for critically
ill neonate (per day) (List separately in addition to primary code)
99482, Selective head hypothermia in critically ill neonate per day (List separately in addition to primary code)
Add-on codes to 99291-99292, critical care, or 99468-99469, neonate IP critical care
Unconditionally packaged (SI N) under OPPS and not paid under the MPFS
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ObservationPaid as a composite under APCs (APC status
Indicator Q3)Two composites in 2013 – 8002 and 8003Requires at least 8 hours (units of 8)With a high level E/M code reported the day before
or day of observationWithout a surgical code reported the day before or
day of observation
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Observation Changes for 2014
Significant increase in packaged services (e.g., lab and stress tests)
Reduction of clinic E/M codes to a single G code (G0463)
Required changes to observation composites
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Extended Assessment and Management Composite (EAM)
In 2013 there were two composite EAMs – 8002 and 8003
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G0378 (8 or more units)Revenue code 762 (observation)Reported with:
G0379 (direct referral) on the same date of service, or99205 / 99215 (level V clinic visit) on the same date or day
before
Reported without a surgical (Status T) procedure on the same day or day before
National APC Rate (2013) = $440.70No diagnosis requirement
Level I Extended Assessment and Management - APC 8002
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G0378 (8 or more units)Revenue code 762 (observation)Reported with:
99284 / 99285 (high-level ED visit), or99291 (critical care), orG0384 (high level Type B ED visit)On the same day or day before the observation
Reported without a surgical (Status T) procedure on the same day or day before
National APC Rate (2013) = $798.47No diagnosis requirement
Level II Extended Assessment and Management APC 8003
High Level E/M
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Extended Assessment and Management Composite (EAM)
Effective 1/1/2014 there will be only one composite EAM – 8009G0378 (8 or more units), revenue code 762
(observation) with no diagnosis requirementReported with an E/M service:
99284 / 99285 (high-level ED visit) 99291 (critical care) G0384 (high level Type B ED visit) G0463 (clinic E/M) Or G0379 (direct referral to observation from physician ofc) On the same day or day before the observation
Reported without a surgical (Status T) procedure on the same day or day before
National APC Rate (2014) = $1,198.91
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G0379 – Direct ReferalG0379 – Direct referral to observation, moved to
APC 608, payment increased to $327.85 (2014) from $175.79 (2013)2012 - reimbursed as a 99211 (APC 604)2013 - reimbursed as a 99205 – new patient clinic
level V2014 – reimbursed between a level IV and V ED E/M
Paid only when observation is not paid Improved reflection of the cost associated
with direct referrals to observation
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Provider-Based ClinicsCMS acknowledges that there is an increasing trend
toward hospital acquisition of physician practicesResulting in increasing numbers of provider-based
clinicsMedicare payments in these clinics are subject to
two co-pays, one for the technical component and one for the professional component
Generally the combination of the two results in a higher co-pay than would be present for a free standing physician’s office
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Provider-Based ClinicsCMS is considering collecting information on these
types of visitsThere several proposed methods for collecting this
information:(1) Creating a new POS (place of service) for off
campus departments of a provider(2) Creating a new modifier that could be reported with
every code provided in an off campus provider based department
(3) Asking hospital to break out costs/charges for these cost centers on the cost report
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Provider-Based ClinicsCMS has received and reviewed the
comments and will let us know what they decide
Watch for more information in the coming year
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Incident-To Guidelines Medicare now requires the compliance with
state law as a condition of payment for services furnished incident to physician and other practitioner services
Would enable the federal government to recover funds paid if services are not furnished in accordance with state law
Should not change anything as providers should have already been following the applicable state laws and state practice acts
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Contact UsRichard Cooley
Phone: 518-430-1144
Email: [email protected]
Matthew LawneyPhone: 845-642-6462
Email: [email protected]
Jean RussellPhone: 518-369-4986
Email: [email protected]
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http://www.EpochHealth.com/
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CPT®
Current Procedural Terminology (CPT®) Copyright 2013 American Medical AssociationAll Rights ReservedRegistered trademark of the AMA
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DisclaimerInformation and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.