Download decision making - the Association of Northern California Oncologists

MEDICARE:
UNDERSTANDING
WHAT IS
HAPPENING AND
PREPARING FOR
2013
Association of
Northern
California
Oncologists
January 2-4, 2013
WE WILL DISCUSS
• Why This Seminar Is Necessary
• Documentation and Chart Review
– Why Review
– Coding Principles & Misunderstandings
• Review Principles
– Medical Necessity Very Important
– Complexity of Decision Making
– Frequency of visits vs illness
• EHR and Templates
– Chief Complaint Issues, Active Problem Issues
– Cloning and Decision Making
• Managing Change
–
–
–
–
MAC Contract for J “E”
2013 fee schedule, Changes
Recovery Auditors (Formerly RACs)
LCDs and NCDs
REPORT ON SPECIAL
STUDIES OF E & M
• Data Studies Show Medical Review is Necessary
–
–
–
–
OIG Findings –Consistent increase in high E&M codes
BESS Data --- Nationwide & Local, 12 or more mos old
CERT Data --- Nationwide & Local, recent findings
Palmetto GBA Data Mining --- Local searches
• Who Was
Reviewed in Recent
E&M
reviews
willStudy
continue!
– Outliers by Service Type / Specialty Type
– Outliers of the Outliers (2 St. Deviations or more)
• What Was Requested
– 5 Charts per Provider per Code, single chart per service
• Purpose
– General Education of Physicians / Offices
– Denials Followed by Contact from POE
– Specific Education for Denied Physicians
TECHNICAL DENIALS
• Many Chart Denials are for Technical
Reasons
– Missing or illegible provider signature or use of
a signature stamp
– Missing or unsigned physician orders
– Illegible documentation
– Failure to provide documentation for all dates
of service requested
• If Technical Denials Prevented or
Corrected--- Claim Paid First Attempt
– Up to 50% denials for technical reasons
– Office staff should prevent that from happening
MEDICARE MANUAL
SAYS:
• Medicare will
reimburse for all
services that are
reasonable and
necessary for the
diagnosis and
treatment of an illness
or injury or to repair a
damaged organ
WE (PALMETTO) SAY:
• Only the
physician
treating the
patient knows
what is
reasonable and
necessary for
that patient
being evaluated
and treated.
•The only way
Palmetto GBA
can know if
something is
reasonable and
necessary is to
read the
complete
documentation
submitted
PURPOSE OF
DOCUMENTATION
• Communicate with Health Care Personnel
– Physicians, colleagues
– Other health care workers& caregivers
– Remind yourself what is going on
• Communicate with Others
– Quality review (PQRI, P4P)
– Peer review (PRO, hospital, licensing
board, credentialing groups)
– Patient transparency
– Protect against liability issues
– Insurance review personnel (pre and
post pay situations)
BEST FORMAT FOR
DOCUMENTATION
• There is no best single format
• Can use any & all variants
–
–
–
–
–
History, Exam, Decision, Order
Subjective, Objective, Assessment, Plan
Pre-printed forms – if specific
Electronic records – if specific
Printed / written legible notes
• Explain to the reviewer
– Nature of patient problems
– How / why patient treated
– What is next and why (decisions)
DOCUMENTATION
POINTS
• Templates/forms OK, but must
be individualized for each visit
• Patient name, date, time, and ID
of who documented chart
• Computerized notes okay if
individualized, but medical
necessity still rules on review
• Require time when service time
related-e.g. face to face time
• If poorly legible, or not properly
signed--we must reject the claim
CODING & DOCUMENTATION
DISTINCTIONS
• NEW PATIENT VS. ESTABLISHED PATIENT
– DIFFERENT CODES AND PAYMENT FOR EACH
– RACS KEEP LOOKING AT THIS DENIAL
– EFFECTS SAME SPECIALTY GROUPS
• PLACE OF SERVICE
– INPATIENT OR OUTPATIENT (E.G. OFFICE)
– HOSPITAL, ED, SNF, ECF, HOME, ASC, OTHER
• •“LEVEL”
OF CARE –GONE FROM MEDICARE 2010
CONSULTATION,
– REGULAR (5 OUTPATIENT, 3 INPATIENT)
– CRITICAL CARE, OBSERVATION, EXTRA TIME
– SPECIAL SERVICES (EYE, MENTAL HEALTH)
DEFINITION: NEW
PATIENT
• PATIENT WHO HAS NOT RECEIVED SERVICES
FROM A PHYSICIAN OF SAME SPECIALTY WHO
BELONGS TO SAME GROUP PRACTICE FOR 3
YEARS
• PATIENTS SEEN BY COVERING OR ON-CALL
DOCTOR CONSIDERED PATIENT OF USUAL
DOCTOR WHO IS UNAVAILABLE
• NO DISTINCTION MADE BETWEEN NEW AND
ESTABLISHED PATIENT IN EMERGENCY DEPT.
• A REFERRAL VISIT NOT NEW IF SEEN FACE TO
FACE FOR ANY OLD OR NEW PROBLEM IN ANY
PLACE OF SERVICE WITHIN 3 YEARS
COGNITIVE (EVALUATION &
MANAGEMENT) SERVICES
• INVOLVE ALL PHYSICIANS WHO EXAMINE AND
EVALUATE PATIENTS
• REQUIRE DOCUMENTATION TO SHOW LEVEL OF
WORK & LEVEL OF CODING FOR REIMBURSEMENT
• ACTIVITY BASED, TIME BASED, OR BOTH
• ALL SURGERY / PROCEDURES HAVE SOME
INHERANT E&M SERVICES INCLUDED
• E&M DOC. GUIDELINES COMPLICATED
• MEDICAL NECESSITY A KEY FACTOR IN DECIDING
APPROPRIATE E&M LEVEL
• NECESSARY TO INTEGRATE DOCUMENTED
CODING WITH MEDICAL NECESSITY OF SERVICE
COMPONENTS OF (E&M)
SERVICES
• CHIEF COMPLAINT
• HISTORY
• EXAM
• DECISION MAKING
• COUNSELING
• COORDINATION
OF CARE
• NATURE OF
PRESENTING PROBLEM
• TIME
CHIEF COMPLAINT
• “A chief complaint is a concise statement
describing the symptom, problem, condition,
diagnosis, or other factor that is the reason for the
encounter, usually stated in the patient's words.”
…..from AMA CPT
• The reason for the encounter often sets the stage
for what is needed in the history, exam, and
decision tree.
• New problems MAY take more effort than old ones
• Medicare does not pay for routine patient visits
except for one NEW TO MEDICARE visit and one
annual healthy assessment visit
Should
99212---infer the work
99213bebilled-not the “regular check up”
denied
PRESENTING PROBLEM
• A presenting problem is a disease,
condition, illness, injury, symptom,
sign, finding, complaint, or other
reason for encounter, with or
without a diagnosis being
established at the time of the
encounter. The E/M codes
recognize five types of presenting
problems that are defined as
follows:
PRESENTING PROBLEM
(OR PROBLEMS)
•
•
•
•
•
Minimal: A problem that may not require the presence of the
physician, but service provided under the physician's supervision.
Self-limited or minor: A problem that runs a definite &prescribed
course, is transient & UNLIKELY to permanently alter health
status OR has a good prognosis with management / compliance.
Low severity: A problem where the risk of morbidity without
treatment is low; there is little to no risk of mortality without
treatment; full recovery without functional impairment is
expected.
Moderate severity: A problem where the risk of morbidity without
treatment is moderate; there is moderate risk of mortality without
treatment; uncertain prognosis OR increased probability of
prolonged functional impairment.
High severity: A problem where the risk of morbidity without
treatment is high to extreme; there is a moderate to high risk of
mortality without treatment OR high probability of severe,
prolonged functional impairment.
ELEMENTS
OF HISTORY
SOCIAL
PAST
HISTORY
• A review of the patient's
past illnesses, injuries, and
treatments with significant
information about:
– Prior major illnesses and
injuries
– Prior operations
– Prior hospitalizations
– Current medications
– Allergies (eg, drug, food)
– Age appropriate immunization
status
– Age appropriate
feeding/dietary status
HISTORY
•An age appropriate
review of past &
current activities with
information about:
- Marital status and
living arrangements
- Current employment
- Occupation history
- Use of drugs, alcohol, &
tobacco
- Level of education
- Sexual history
- Other relevant social
factors
REVIEW OF SYSTEMS
• An inventory of body systems seeking
•Constitutional
ourinary
to identify •Genit
signs and/or
symptoms that
symptoms (fever,
Musculoskeletal
the patient•may
be experiencing or
experienced.
For the purposes of
weight loss,has
etc.)
• Integumentary
the CPT codebook the following
•Eyes
(skin
and/or
breast)
elements of
a system
review
have
•Ears, nose,been identified
• Neurological
…
• The review•ofPsychiatric
systems helps define
mouth, throat
the problem, clarify the differential
•Cardiovascular
• Endocrine
diagnosis, identify needed testing, or
•Respiratory
• Heme
- lymphatic
serves as baseline
data
on other
systems that
might be affected by any
•Gastrointestinal
•Allergy-immunology
possible management options.
REVIEW OF SYSTEMS
• In all documentation, you should see
all positive findings and pertinent
negative findings
• In regard to the present illness, we
would expect:
– Positive findings of system related to
present illness
– Pertinent negative findings to systems
related to present illness
– Pertinent findings or comment on
changes in systems that are listed as comorbidities or secondary problems
• Unrelated systems can be “within
normal limits, negative, normal or
EXAM
DOCUMENTATION
•
PROBLEM FOCUSED
•
EXPANDED PROBLEM • Limited exam affected
body area & symptomatic
FOCUSED
related body areas
• DETAILED
•
COMPREHENSIVE
• Limited exam of affected
body area / organ sys.
• Extended exam of
affected body area and
any other symptomatic or
related body area.
• General multi-system …
..Or complete single
system and symptomatic
or related body areas
EXAM
DOCUMENTATION
• For the purposes of these CPT
definitions, the following body areas
are recognized:
–
–
–
–
–
–
–
Head, including the face
Neck
Chest, including breasts and axilla
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
12 TYPES OF EXAMS
Multispecialty and 11 single specialty exams
1.
2.
3.
4.
5.
6.
MULTISYSTEM
CARDIOVASCULAR
E.N.T.
OPHTHALMOLOGY
G.U. (Female)
G.U. (Male)
7. HEME / LYMPHATIC
8. MUSCULOSKETAL
9. NEUROLOGICAL
10 PSYCHIATRIC
11 RESPIRATORY
12 SKIN
ANY PHYSICIAN CAN BILL A
MULTI-SYSTEM EXAM
ANY PHYSICIAN CAN BILL A
SINGLE SYSTEM EXAM
DECISION MAKING
• Decision making refers to complexity of
establishing a diagnosis and-or selecting
management options as measured by:
– Number of possible diagnoses and/or the number
of management options that must be considered
– Amount and / or complexity of medical records,
diagnostic tests, and/or other information that
must be obtained, reviewed, and analyzed
– The risk of significant complications, morbidity,
and-or mortality, as well as co-morbidities,
associated with the patient's presenting
problem(s), the diagnostic procedure(s), and/or
the possible management options
COMPLEXITY OF
DECISION MAKING
Comorbidities / underlying
diseases, in and of themselves,
are not considered in selecting a
level of E/M services unless their
•Four types of medical decision making are recognized:
presence significantly increases
straightforward, low complexity, moderate complexity, and high
complexity.
To qualify for a given
decision making, two
the complexity
of type
theofmedical
of the three elements in Table 1 must be met or exceeded.
decision making.
•Comorbidities/underlying
diseases, in and of themselves, are
not considered in selecting a level of E/M services unless their
presence significantly increases the complexity of the medical
decision making.
DOCUMENTATION OF
DECISION MAKING
• There are instances where no change in
care is a complex and high level
decision BUT
– This should be documented for review
– Many EHR do not allow space for this
– May be shown in “rule outs”, “possible dx”, or
elements of physician thoughts
– Orders or plans may show decision making
– Decision making relates to that visit only
– Where decision making is used to create
higher level of code, we expect some
indication in record
SELECTING A CODECPT AVERAGE TIME
• 99211: Typically, 5 minutes are spent performing
or supervising these services.
• 99212: Typically physicians spend 10 minutes face
to face with the patient.
• 99213: Typically physicians spend 15 minutes face
to face with the patient.
• 99214: Typically physicians spend 25 minutes face
to face with the patient.
• 99215: Typically physicians spend 40 minutes face
to face with the patient.
•
Counseling and/or 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.
MEDICAL NECESSITY OF
E&M VISITS--OFFICE
• New Patient Visits:
– No visits for 3 years by physician
– Require all 3: History, PE, Decision making
• Subsequent Patient Visits
–
–
–
–
–
–
Require any 2: Hx, PE, Decision
99211: Brief visit, no MD (BP check, sutures out)
99212: Single problem, easy to dx and resolve
99213: Average 10-15 follow up several problem
99214: Complex patient, mult problems
99215: Require extensive visit with full workupnew serious problem or patient with
major risk to organ system or life
E&M VISITS-HOSPITAL
• Initial In-Patient Visits:
–
–
–
–
First visit in hospital – and Initial Referral Visit
Require all 3: Hx, PE, Decision Making
99221, 99222, 99223 levels if meets criteria
Usually full H&P needed by Attending MD
• Subsequent Patient Visits in Hospital
–
–
–
–
Require any 2: Hx, PE, Decision
99231: Brief visit-better-discharge soon
99232: Average day, IVs, Dx tests, active Rx
99233: New or worsening problems-
• Discharge day - discharge codes for
attending physician- (99231 for others)
CRITICAL CARE
CODES
• Critical care is the direct
delivery by a physician(s)
of medical care for a
critically ill or critically
injured patient. A critical
illness or injury acutely
impairs one or more vital
organ systems such that
there is a high probability
of imminent or life
threatening deterioration
in the patient's condition
•
•
•
•
•
•
•
•
•
•
The following services are
included in critical care
Interpretation of cardiac
output measurements
Chest x-rays
Pulse oximetry
Blood gases
Information data stored in
computers (eg, ECGs,
blood pressures,
hematologic data)
Gastric intubation
Temporary
transcutaneous pacing
Ventilator management
Vascular access
procedures
being
in an MIN.
ICU does not necessarily
• Just
99291
– 1ST 30-74
care codes!!!
• 99292 warrant
– ADD. 30critical
MIN
TOOLS YOU CAN USE
FROM PALMETTO
•
•
•
•
•
•
•
•
•
E&M Score Sheet Tool
Modifier Lookup
Denial Codes
National and Local Coverage Policies
On-line Claims Management Tool
Local Fee Schedules
Medicare Forms
FAQs
More available on our website
WHY AUDITS AND REVIEWS
ARE NECESSARY
• Many physicians do not understand E&M
coding rules – or don’t want to
• Electronic Records tend to automatically
up-code many visits
• Strict counting of number of elements does
not always justify code
– Individual services must be reasonable and
necessary for patient and date of service
– Frequency of services must be reasonable and
necessary for patient
• Outside reviewers find high number coding
errors
– CERT
– RAC
-- OIG
--ZBIC
PALEMTTO GBA DATA COLLECTED
…37 pages of physician names
…1065 docs had > 12 level 5 visits per year
…Large variety of specialties involved
…Northern California Only…if all three states
taken together would be three times higher
Radiology Srvs in California
71010 & 71020 … 5-8-2010
• Southern California:
– 56% of the total amount denied due to NO
DOCUMENTATION received
– 27% of the total amount denied was due to NO
PHYSICIAN ORDERS received
– 8% of the total amount denied was charges
deemed to be NOT MEDICALLY NECESSARY
based on LCD for Radiologic Examination Chest
– 8% of the total amount denied was for a
combination of biller errors, illegible
documentation, incorrect / incomplete date of
service or patient identification on
documentation received, and missing, invalid,
illegible provider signature
Radiology Srvs in California
71010 & 71020 … 5-8-2010
• Northern California:
– 72% of total amount denied due to NO
DOCUMENTATION received for review
– 9% of total amount denied for invalid, illegible or
missing PROVIDER SIGNATURE
– 9% of the total amount denied was charges
deemed payable to ANOTHER PROVIDER billing
same procedure, date of service & beneficiary
– 10% of the total amount denied for a
combination of illegible documentation,
incorrect-incomplete date of service or patient
ID on documentation received, no chest X-ray
report included with documentation, and
charges that were deemed to be not medically
necessary based on LCD
EXAMPLE: SPECIALTY 11
(INTERNAL MEDICINE)
• There were 5,459 claims reviewed, out of which
3,724 claims were denied. The total dollars denied
resulted in a charge denial rate of 49%
• The top denial reasons identified from the review
are:
– 46 percent – Missing or incomplete documentation for this
date of service
– 35 percent – Level of service billed not supported; Downcoded claim
– 7 percent – Illegible documentation
– 4 percent – Incorrect / incomplete / illegible patient
identification or date of service
LOOKING AT MORE CLAIMS
• Reasonable and Necessary
trumps pages and pages of
documentation if only done
for sake of “scoring points”
• Electronic health records try
to increase billed codes
• Electronic health records
–
–
–
–
Often inconsistent
Sometimes incoherent
Still in their infancy
Doctors don’t know how to use
or update properly
No more,
no more !!
LOOKING AT MORE CLAIMS
• Electronic Records Must be
kept up to date for any visit
• Concurrent illness must be
concurrent & significant
• Decision Making
– Helpful if explained / listed / or
documented
– Important to list changes in
care or diagnoses
– Lab review should be included
if records asked for in a review
– Excess verbiage on some EHR
still does not give extra value
Get me
outta here
Review of symptoms
negative---is this in past
week or in past ever….and
is it necessary
Problem list never
updated and
frequently has
duplicate or even
opposite diagnoses
73 Y/O female
inpatient hosp or SNF
ID note:
afebrile but
draining
wound—
brief
history
Review of
Follow up visit 3 weeks later
lab and
low level
decision
making
THOUGHTS FROM AN
ADDLED REVIEWER
• A Chief Complaint should not be a “regular visit”
• Documentation should include all positive and
pertinent negative findings
– ROS should not be negative, normal, or WNL regarding the
chief complaint or other positive problems
• Exam should include all positive and pertinent
negative findings
– Exam of principal problem or reason for visit should not be
normal, WNL or negative
– If patient comes for oncology follow up, expect exam of
areas at risk and all related structures
– Unrelated areas of body can be examined and stated as
within normal limits.
– Frequent visits should are not always high level visits
MORE THOUGHTS FROM
AN ADDLED REVIEWER
• Repeated full histories (if unchanged) should not be
cloned for each visit
• Documentation of most any visit should not be
exactly the same –word for word-- as former visits
– Complicated patients with multiple problems nearly
always have something different related to one problem
• Decision making is subjective
– Some decisions come automatically to some docs and not
to others
– Try to explain your thoughts as to how you plan to test,
diagnose or manage a patient
– Chronic conditions that relate to your visit count
– True morbidity and risk to patient also count toward
decision making
WHAT IF ONE IMPORTANT
ELEMENT NOT PERFORMED
• No real history available
– Patient comatose
– Patient demented
– Patient drugged
• Get history from other source (addendum)
– From family
– From old or new chart
– When patients wakes up
• If patient on way to emergency surgery
– Key elements (heart, lung, vital signs)
– Rest of exam when patient available
• Emergency decision making usually high level
RESPONDING TO MEDICAL
REVIEW & RECORD REQUESTS
• WHO CAN ASK FOR
RECORDS / DOWNCODE OR
DENY PAYMENT
– MEDICARE A/B ADMIN.
CONTRACTORS (MACs)
– PROGRAM INTEGRITY
(ZPIC) CONTRACTOR
– CERT CONTRACTOR
– RAC CONTRACTOR
– QIO
– BUNDLING AND MEDICAL
UNLIKELY EDITS (MUE)
– PRIVATE INSURANCE
COMPANIES (FOR
MEDICARE ADVANTAGE)
MAC REVIEWS: WHO
GETS REVIEWED
DATA OUTLIERS
• UNUSUAL FREQUENCY OF VISITS
• UNUSUAL LEVEL OR PLACE OF
SERVICE FOR PATIENT
• POOR DOCUMENTATION IN PROBE
REVIEWS SENT TO CONTRACTOR
• PATIENT COMPLAINTS
• REPEAT FALLOUTS & WARNINGS
• POSSIBILITY OF FRAUD
PREPARE FOR REVIEWS: DO
1. GET PERSONALLY INVOLVED
2. COPY ALL OFFICE, FACILITY OR
OTHER RECORDS REQUESTED:
--PROGRESS / THERAPY NOTES
(CURRENT AND EARLIER IF
HELPFUL TO EXPLAIN)
--NURSING NOTES, CLINICAL
OBSERVATIONS, AND ANY
CONSULT NOTES IF HELPFUL
--LAB & DIAGNOSTIC TESTS IF
RELATED TO SERVICE
--ANY CHANGE IN DX, MEDS, OR
THE CURRENT CONDITION
3. WHEN IN DOUBT SEND MORE
RATHER THAN LESS TO SUPPORT
MEDICAL NECESSITY OF SERVICE
PREPARE FOR REVIEWS: DO
4. CHECK FOR CORRECT DATES & NAMES
---CORRECT PATIENT & DATES OF SERVICE
---CORRECT PHYSICIAN
5. SUBMIT TIMELY AND TO CORRECT
ADDRESS REQUESTED ON LETTER
6. KEEP RECORD OF INDIVIDUAL ASKING FOR
YOUR RECORDS AND WHY (WHICH
SERVICES) THEY ARE ASKING FOR
7. CHECK FOR LEGIBILITY – CAN RETYPE
NOTES IF ALSO SEND ORIGINAL
8. CALL IF ANY QUESTIONS –
---LOCAL CONTRACTORS CAN HELP
---NSMA MAY HAVE ANSWERS ALSO
IF YOU HAVE PROBLEMS
YOU CANNOT RESOLVE
• CALL OR CONTACT THE IDENTIFIED PERSON AT
PALMETTO & ASK FOR AN IN PERSON OR
TELEPHONE MEETING---or CALL OUR PCC
– YOU SHOW YOU CARE ABOUT THE SITUATION
– THE CONTACT ALONE MAY TEACH YOU HOW TO
SOLVE THE PROBLEM & FIX THE CLAIMS
• CALL ANCO OR YOUR COUNTY ASSOCIATION OR
CALIFORNIA MEDICAL ASSOCIATION FOR HELP
– MEDICARE CONTRACTORS CARE ABOUT GOOD
RELATIONS WITH ORGANIZED ASSOCIATIONS
• REMEMBER, YOUR ASSOCIATION STAFF CAN CALL
US TO HELP EXPLAIN THE REGS AND SOLVE THE
PROBLEMS—WE ALL WANT TO HELP
CERT AND MEDICAL
INTEGRITY CONTRACTORS
• CERT Contractors: Livanta & Advanced Med
– Ask for only a single chart or case
– Purpose to review the reviewers
– If denied money must be returned
– Appeals possible if you disagree
• ZPIC (Zone Program Integrity) Contractors
– CalBisc (SafeGuard Systems) in J-1
– Potential fraud or abuse cases
– Respond promptly, get all info, may be
misunderstanding with patient
RAC-RECOVERY
AUDITORS
• HDI (HealthDataInsights) for J1
• Reviews old paid claims (up to 3
years from date of claims)
– Reviews medical necessity
– Reviews proper coding
– Paid a % of what it brings in
• Look at medical necessity &
incorrect coding for over and underpayment in claims already paid
• Can appeal denials several levels:
MAC-QIC-ALJ, etc.
RESPONDING TO ANY
REQUEST FOR RECORDS
• Have a set office process for dealing with all ADRs
(Additional Record Requests)
• Have one individual responsible for sending all
records as part of the set office process
– Experienced office person, or clinical person, or both
• Have a check off sheet that involves
–
–
–
–
–
Legibility (can add typed / printed addendum)
Correct name, date, physician listed in request
Signature (signature sheet or attestation if needed)
Correct address to send records
Timeliness of records being sent
• Know how and where to get hospital records
• Send by certified mail (or equivalent)
APPEALS PROCESS
• Initial Determination
from Palmetto GBA
• Redetermination from
Palmetto GBA
• Qualified Independent
Contractor (QIC)
• Administrative Law
Judge (ALJ)
• Department Appeals
Board (DAB)
• Federal Court
APPEALS PROCESS
• Instructions come with any
denial
– Time frames for next level
– Addresses for appeal
• No penalty for new appeals
– Fresh person with each
appeal level
– Often higher level review
• Recommend appeals with
CERT, RAC
• Useful to discuss with med
organizations and specialty
societies to see if other
appeals win
JURISDICTION “E”
MEDICARE CONTRACT
• As of January 1, initial JE contract award
to Noridian Administrative Services
• Two contract challenges were initiated
– Result to be announced end of January
– Possible outcomes: initial award remains,
award reversal, or re-bidding starts over
• Palmetto will administer claims through
end of June under all circumstances
– All Medicare services to physicians will remain
– CACs will continue
• If transition occurs, it will be smooth and
seamless to physicians
PHYSICIAN FEE
SCHEDULE
• 2013 Fee schedules are on-line now
• Factors affecting fee schedules:
– SGR (Sustainable Growth Rate)
– Sequestration based on Congressional law
– Individual factors for some specialties (e.g.
second tests for Radiology, Cardiology,
Ophthalmology)
• Remember, new or changed CPT or HCPCS
codes could have new fees and descriptors
• Congressional law will effect fee schedule...
changes will be on web when in effect
PHYSICIAN FEE
SCHEDULE
• Finding the fee schedule
– WWW. PalmettoGBA.com\J1B
– Click Fee Schedules under “Top Links”
box upper left
– Next screen, under “search this area”
select California and the region
– Look through the Excel spreadsheet for
the codes you want.
• Alternative: click through the CMS
Medicare Data Base in the upper part
of page
EMR PROBLEMS
•
•
•
•
•
Cloning: cutting and pasting each visit
Medical necessity of level of service
Inconsistency of records: Hx, ROS, Exam
“Regular” or “follow up” visits
Documentation of individual visit
uniqueness for that day
• Documentation of decision making
• Activeness and duplication of chronic
problems and meds in list
• Signatures, signatures, signatures
EMR PROBLEMS
• Don’t forget level 2 “Meaningful Use”
for 2013.
• Information found in CMS website
• http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/
Downloads/beginners_guide.pdf
• http://www.cms.gov/EHRIncentivePrograms
RECOVERY AUDITORS
(FORMALLY RACS)
• Recent Focuses:
–
–
–
–
–
–
–
–
–
–
Short hospital inpatient vs outpatient stays
New vs subsequent visit: eye and custodial care
Multiple endoscopic procedure codes
Excessive units ultrasound guidance
Excessive Units of Microslide Consultation
Pulmonary edema, resp. failure as inpatient vs
outpatient
Metastasis as secondary diagnosis (MS-DRG)
Incorrect billing CT scans
Hip fractures without complications MS-DRG
Hepatobillary disorders MS-DRG
RECOVERY AUDITORS
(FORMALLY RACS)
• Things to consider:
– Hospital admission by MD who knows
patient…REASON FOR SURGERY, ADMISSIOM
– Document all primary and secondary problems
– Use office lab sheets and progress notes when
they document hospital condition
• Accurate coding for office services
– Remember modifiers, add on codes, IV codes
– Remember multiple surgery rules
– Document to support unusual test or procedure
• Appeal all denials, but have documentation to
support appeals. Office notes PLUS specialty
guidelines, peer-reviewed literature, etc.
UNDERSTANDING NCDs
AND LCDs
• NCD: National Coverage Determination;
– Made by CMS cannot be altered by contractor
– Open for comments, from society, industry, interest groups
– Same across country, slow, and very hard to change
• LCD: Local Coverage Determination;
–
–
–
–
Made by Palmetto, drafts presented tor advice & input
Formal open meetings and CACs
Must answer all comments
Reconsiderations if new evidence presented or new codes
• Time Frames;
– Draft displayed 15 days prior to CAC
– 45 day notice and comment
– 30 day after final published before effective
UNDERSTANDING NCDs
AND LCDs
• LCDs and many NCDs have associated
coding information
– Which CPT and ICD codes ALWAYS covered
– Which CPT and ICD codes NEVER covered
• NCD & LCD usually have automated editing
• Understand which NCDs and LCDs effect
your practice: they explain exactly how to
code and bill.
• There is a new “exception process” for
LCDs when appealed with adequate data
and supporting evidence
FINAL THINGS TO
REMEMBER
• Medical Necessity Trumps any level of detail if different
• With electronic records
– Watch for cloning (same words each visit)
– Remember chief complaint and present illness
– Remember decision making is important aspect
• Complexity of decision making is important aspect
– Concurrent related diseases
– Number and interrelationships of meds
– Risk to patient of action or inaction
• Inpatient consults are initial hospital visits
– Level of service compared to CPT requirements
– Remember reasonable and necessary trumps # of pages
• Expect all positive exam signs and symptoms and all
pertinent negative ones
– If most negative, not likely a high level visit but give credit
• We can check dates of last few visits
– How many appendix operations does one repeat
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