Joslin Diabetes Center Affiliated Programs Billing & Coding DiscussionApril 22, 2009

• Every Affiliate should have a scheduled annual chargemaster and encounter form review on an annual basis

• Your finance area should review your fee schedule to make sure that fees are set for each code at the highest level of reimbursement by all payers

• Never set your fee at a level lower than any payer’s reimbursement, as payers will always pay the lesser of charge or negotiated reimbursement

• All hospital and professional encounter forms should be reviewed on an annual basis by a hospital certified coder and a professional certified coder

• Review with your physicians and nurse practitioners to determine if there are any injections or other procedures being done that are not being captured

• Use a chargemaster tool for annual review (attached)

Annual Chargemaster Review

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This is a tool that we hope will assist you as you complete your annual ICD9, CPT4 and HCPCS assessment for your 2009 Charge Master review. Below are a series of questions regarding your current charges and practices. This information will be helpful in creating hospital you meet with your chargemaster review team for your annual update.- Have you had your encounter form reviewed by a hospital coder and a professional coder?- Are there any procedures or services on your encounter form that you no longer perform?- Are there any procedures or services that you perform that are not on the encounter form?- Are there any procedures or services on your encounter form where you know the CPT4 code is incorrect?- Are there any drugs or medications that you routinely administer or often use?If YES, where do you currently get the drugs/medications?- Do you inject or infuse these drugs or do you give vaccines?- Please bring with you a list of drugs/medications used in your area.- Do you administer Hep B, Pneumococcal, or Influenza(Flu) Vaccine(s)?- Do you inject allergens, toxoids, or venoms for clinical testing?- Do you perform Skin tests such as PPD for TB, Candida, Mumps, etc.?- Do you perform any lab tests such as Urinalysis, Occult Blood Stool Guaiac, etc.- Do you perform Venipuncture?

2009 Chargemaster Review Tool

2009 Chargemaster Review Tool (continued)- Do you perform any tests that require a machine such as EKG, Spirometry, Radiology, etc.?- Who owns the machine?- When was it purchased?- Who interprets the test?- Are there any supplies, where the cost is more than $25, for which you currently don’t charge?- Do you ever write in CPT4 codes/procedures under an “Other” category on the Encounter Form?- If a procedure is written in the “Other” field, do you do this more than one time per month?- Are you aware of any procedures in your area where the professional and facility CPT4 varies? (ex, EKG where Interpretation is 93010 and Tracing is 93005).- Do you know of any new 2009 ICD-9 codes that should be added to your encounter form?- Do you know of any new 2009 CPT4 codes that should be added to your encounter form?- Do you know of any new 2009 HCPCS codes that should be added to your encounter form?- Medical records review for compliance with hospital standard (volume, etc.)- How do you designate whether a visit qualifies for a professional fee if a resident or other physician extender sees the patient? (i.e., QA check for MD countersigning note, teaching MD rules, etc?)- Please bring a sample of a Managed Care referral waiver with you to the review meeting.

Codes that should be considered for your Billing Ticket and your Chargemaster

  G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes G0109 - Diabetes outpatient self-management training services, group session (2 or more),

per 30 minutes 97802 – Medical nutrition therapy; initial assessment and intervention, individual, face-to-face

with the patient, each 15 minutes 97803 – Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with

the patient, each 15 minutes 97804 – Medical nutrition therapy, group (2 or more individuals), each 30 minutes G0270 – Medical nutrition therapy; reassessment and subsequent intervention(s) following

second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes

G0271 – group (2 or more individuals), each 30 minutes 99406 – smoking and tobacco use cessation counseling visit; intermediate, greater than 3

minutes up to 10 minutes 99407 - smoking and tobacco use cessation counseling visit; intensive, greater than 10

minutes 98960 – Education and training for patient self-management by a qualified, nonphysician

professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

Codes that Should be on your Encounter Form and Chargemaster

Codes that Should be on your Encounter Form and Chargemaster (continued) 98961 – 2-4 patients, initial or follow-up 98962 – 5-8 patients, initial or follow-up

These education and training codes are not covered by Medicare A physician must prescribe the education and training A qualified healthcare professional must provide the services using a standardized curriculum (The nonphysician’s qualifications and the program’s contents must be consistent with guidelines or standards established or recognized by a physician society, nonphysician healthcare professional society or association or other appropriate source – (according to the CPT book introductory patient self-management education and training notes)

95250 – Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up,, calibration of monitor, patient training, removal of sensor, and printout of recordings

95251 - Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; physician interpretation and report

99091 – Collection and interpretation of physiologic data (e.g. ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patients and/or caregiver to the physician or other qualified healthcare professional, requiring a minimum of 30 minutes of time.

 

Prolonged Service Codes – A Revenue Opportunity

Another notable change in the E/M section is under the prolonged physician service codes with direct patient contact (99354–99357). The instructions were revised to clarify that these time-based add-on codes may be reported in addition to the primary E/M service (at any level), which has a typical or specified time published in the CPT code book. As a result of this clarification, modifier 21, prolonged evaluation and management services, was deleted.

Prolonged Services Definitions In the office or other outpatient setting, Medicare will pay for prolonged physician

services (CPT code 99354) (with direct face-to-face patient contact that requires one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT code. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services with CPT code 99355.

In the inpatient setting, Medicare will pay for prolonged physician services (code 99356) (with direct face-to-face patient contact which require one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.

Note: You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E&M) codes.

Prolonged Service Codes – A Revenue Opportunity (continued) You may use code 99355 or 99357 to report each additional 30 minutes beyond the

first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 - 30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Required Companion Codes Please remember that prolonged services codes 99354 99357 are not paid unless

they are accompanied by the companion codes as described here. The companion E&M codes for 99354 are: Office or Other Outpatient visit codes (99201 - 99205, 99212 - 99215), Office or Other Outpatient Consultation codes (99241 - 99245), Domiciliary, Rest Home, or Custodial Care Services codes (99324 - 99328, 99334 -

99337), Home Services codes (99341 - 99345, 99347 - 99350);   The companion E&M codes for 99355 are 99354 and one of its required E&M codes. The companion E&M codes for 99356 are the Initial Hospital Care and Subsequent

Hospital Care codes (99221 - 99223, 99231 - 99233), the Inpatient Consultation codes (99251 - 99255); Nursing Facility Services codes (99304 -99318).

The companion codes for 99357 are 99356 and one of its required E&M codes.

Prolonged Service Codes – A Revenue Opportunity (continued) Requirement for Physician Presence You may count only the duration of direct face-to-face contact with the patient

(whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. 

You cannot bill as prolonged services: In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or

In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient's condition, for end of a therapy, or for use of facilities.

Documentation Unless you have been selected for medical review, you do not need to send the

medical record documentation with the bill for prolonged services. Documentation, however, is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.

You must appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service

 

Prolonged Service Codes – A Revenue Opportunity (continued) Use of the Codes You can only bill the prolonged services codes if the total duration of all physician or

qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).

Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting) If the total direct face-to-face time equals or exceeds the threshold time for code

99354, but is less than the threshold time for code 99355, you should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.

If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.

Table 1 displays threshold times that your carriers and A/B MACs use to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings, including outpatient consultation services and domiciliary, rest home, or custodial care services and home services codes. The AMA CPT coding-derived changes are highlighted and noted in bolded italics.