Download Common E/M Service Documentation Errors

Michelle Lott, CPC, CPMA
Associate Director, WSMA Practice Resource Center
Michelle M. Lott, CPC, CPMA
Health Insurance Coding Specialist, WSMA
Phone:
Fax:
Email:
206.441.9762
800.552.0612
206.441.5863
[email protected]
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Agenda
• Describe the nuisances of EM Coding and Documentation and
how this impacts the reimbursement of Medical Practices.
• Identify the rules and interpretation for proper usage of
Modifiers, including the new -X{EPSU} modifier that supplement
Modifier 59.
• Identify common reason for claim denials and how to avoid
these issues in your practice.
• Describe the Medicare’s Value Based Modifier and how it will
impact reimbursement.
3
What is medical documentation?
Medical documentation gives you a starting
point and basis for planning patient care. It
facilitates the following:
• A basis for planning care of your patients
• Communication among physicians and other health care
professionals
• Accurate and timely claim reviews and payments
• Justification for claim payments
• Legal protection for you and your patients
• Protection of your bottom line
4
Documentation Improvement Program
Documentation is not about administrative
burden, it’s about good patient care!
• Clinical Improvements.
o Quality and Efficiency Ratings
• Compliance with Payer Policies and Guidelines
o Ensure prompt and accurate payment for covered services.
• Support Reimbursement.
o Protection against audits and negative financial penalties.
• Improved healthcare delivery.
o Value Based Payments
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Steps to Bulletproof Documentation
Ensure Compliance
• Create a coding policy and procedures that ensure
compliance.
Educate Staff
• Provide coding education to coders and CDI staff and
provide documentation standards to physicians. Coders
do not need to know how to document and physicians do
not need to know how to code.
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Steps to Bulletproof Documentation
Communicate
• Develop communication methods between coders, CDI
staff and physicians. Good communication tools can
equal better documentation with more accurate code
assignments.
Monitor
• Audit and monitor physician documentation and coding
assignments.
7
Steps to Bulletproof Documentation Review
• Put in place a pre-bill review that can enhance your monitoring
and provide an extra measure for those services that have been
problematic.
Give Feedback
• Have an action plan to give praise or take corrective action as
needed.
Repeat
•
The education, monitoring and review process should be
continuous and cycle the through the organization’s review
plan.
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10 Principles of Documentation for Medical
Records
• 1 - The medical record should be complete, legible, and make
sense.
• 2 - The documentation of each patient encounter should
include:
o the date and reason for the encounter;
o appropriate history and physical exam in relationship to the
patient’s chief complaint;
o review of lab, x-ray data and other ancillary services, where
appropriate;
o assessment and a plan for care (including discharge plan, if
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appropriate)
10 Principles of Documentation for Medical
Records
• 3 - Past and present diagnoses should be accessible to the
treating and/or consulting physician.
• 4 - The reasons for and results of: x-rays, lab tests and other
ancillary services should be documented or included in the
medical record.
• 5 - Relevant health risk factors should be identified
• 6 - The patient’s progress, including response to treatment,
change in treatment, change in diagnosis, and patient noncompliance, should be documented.
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10 Principles of Documentation for Medical
Records
• 7 - The written plan for care should include, when appropriate:
o treatments and medications, specifying frequency and
dosage;
o any referrals and consultations;
o patient/family education; and
o specific instructions for follow-up.
• 8 - The record should support the intensity of the patient
evaluation and/or the treatment, including through processes
and the complexity of medical decision-makings it relates to
the patient’s chief complaint for the encounter.
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10 Principles of Documentation for Medical
Records
• 9 - All entries to the medical record should be dated and
authenticated.
• 10 - The CPT/ICD-9-CM codes reported on the CMS-1500
claim form should reflect the documentation in the
medical record.
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Documentation Best Practices
With documentation of medical records,
particular emphasis must be placed on the
five factors that improve the quality and
usefulness of charted information.
•
•
•
•
•
Accuracy
Relevance
Completeness
Timeliness
Confidentiality
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Responsibilities of the Coders
•
•
Must be capable of finding rules governing coding for each
payer and apply them to achieve 100 percent accuracy.
In the absence of such rules, be able to research and
analyze guidelines from accepted authorities to ensure that
the ultimate code decision is reasonable.
14
Are You Always Right? Can You Prove It?
Common criteria supporting code decisions can
be problematic
•
•
•
•
•
•
This is the way I was taught to do it.
This is what the carrier told me to do.
I’ve been coding this way for years.
Everyone does it this way.
A consultant/coding mentor told me to do it this way.
This was the solution recommended in a trade association
publication.
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Spelling Out Medical Necessity
• Medical necessity is largely determined by the payer
community, usually assigned to them by your contract.
o The "General Principle of Medical Record Documentation" from the Federal
Documentation Guidelines is:
o "If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred."
o The provider must document the diagnosis for all procedures that are
performed. The provider also must include the diagnosis for each
diagnostic test ordered. A common error seen when reviewing medical
documentation is that the provider will document a diagnosis and indicate
tests ordered, but it is unclear that all the tests ordered are for the diagnosis
documented in the assessment.
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Documentation and Coding that Demonstrates
Medical Necessity
• Only the documentation found in the patient's medical record
should lead coders to the diagnosis(es) relevant to a claim.
o Given the many physiological elements or even organ systems involved in
most conditions, it is commonly the case that a patient's clinical condition
legitimately may be described in a number of different ways, at a number
of different levels, and by a number of different (and all reasonable) code
selections.
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Documentation and Coding that Demonstrates
Medical Necessity
• As long as the documentation reflects the reality, the coder will
not be led to an inappropriate diagnosis. Similarly, a coder's
familiarity with NCD or LCD coding requirements promotes
correct billing since these coverage determinations are written
to assist the coder search for the specific conditions that allow
claim reimbursement.
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Medical Necessity
• Understanding and determining medical necessity can be very
complex for physicians, clinicians, coders, and billers.
o A physician or clinical provider of care may have a
completely different understanding, interpretation, and
definition of medical necessity than the patient or a patient’s
family member. A third-party insurance payer may also have
another completely different understanding and application
of the term.
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Medical Necessity
• Medical necessity documentation from a physician or provider
should include the following:
o Severity of the “signs and symptoms” or direct diagnosis
exhibited by the patient. This is our diagnosis driver, and
multiple diagnoses may be involved.
o Probability of an adverse or a positive outcome for the
patient, and how that risk equates to the diagnosis currently
being evaluated.
o Need and/or availability of diagnostic studies and/or
therapeutic intervention(s) to evaluate and investigate the
patient’s presenting problem or current acute or chronic
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medical condition.
Medical Necessity
• Here are some examples of what some third party payers are
currently including in their medically necessary verbiage:
o Treatment is consistent with the symptoms or diagnosis of the
illness, injury, or symptoms under review by the provider of
care.
o Treatment is necessary and consistent with generally
accepted professional medical standards (i.e., not
experimental or investigational).
o Treatment is not furnished primarily for the convenience of
the patient, the attending physician, or another physician or
supplier.
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Medical Necessity
• Here are some examples of what some third party payers are
currently including in their medically necessary verbiage:
o Treatment is furnished at the most appropriate level that can
be provided safely and effectively to the patient, and is
neither more or less than what the patient is requiring at that
specific point in time.
o The disbursement of medical care and/or treatment must
not be related to the patient’s or the third party payer’s
monetary status or benefit.
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Common E/M Service Documentation Errors History
•
•
Indicate clearly the chief complaint and/or reason for the
visit.
o Do not limit the chief complaint to “follow-up” without
identifying the problem(s) being followed.
Describe the history of the present illness fully and in such a
way that the nature of the presenting problem is clear.
23
Common E/M Service Documentation Errors History
•
•
Record Past/Family/Social History (PFSH) appropriately
considering the clinical circumstance of the encounter.
o Do not use the term “non-contributory.”
Do not record unnecessary information solely to meet
requirements of a high-level service when the nature of the
visit dictates a lower-level service to have been medically
appropriate.
24
Common E/M Service Documentation Errors –
History
•
Record the Review of Systems (ROS) appropriate for the
clinical circumstance of the encounter.
o Document an ROS for the system(s) related to the
presenting problem. It is required for all levels of systemic
review (meaning that it is required for all codes except
the least codes in all code families).
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Common E/M Service Documentation Errors –
History
•
Documentation examples of what counts as a complete
ROS:
o “Except as above, all other systems are negative.”
o “All other systems reviewed and are negative.”
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Common E/M Service Documentation Errors –
History
•
Documentation examples of what does not count as a
complete ROS:
o “ROS – All other negative”
o “ROS is non-contributory”
o “ROS otherwise unremarkable”
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Common E/M Service Documentation Errors –
History
•
Per CMS Guidelines: History of Present Illness and Chief
Complaint are to be performed by the physician or
non-physician practitioner.
o Information gathered by ancillary staff may be
considered but must be confirmed and completed
by the physician.
28
Common E/M Service Documentation Errors –
History
•
Reviewing information obtained by ancillary staff and
simply writing a note “Reviewed and accepted” is not
acceptable documentation for CMS.
o Better to document “Reviewed and Confirmed” or
add additional detail to the information gathered
by ancillary staff.
29
Common E/M Service Documentation Errors –
History
•
Documenting Status of Chronic Conditions
o Documentation should show what actions the physician
is taking concerning these conditions and how they
affect the chief complaint.
o Just because the patient has chronic conditions does not
indicate a high level of service.
o Example: Some providers use statements such as the
following to justify the regular use of high-level
procedure codes. "My office represents a Level 3
Trauma Center;" "I'm a specialist"; "Other physicians
send their sicker and needier patients to me."
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Common E/M Service Documentation Errors –
History
•
•
•
Documenting status of Chronic Conditions must provide a
description of the condition.
Inappropriate to list the condition with just a status of
“stable”.
Example:
o HPI: 1) HTN, pressures running in the 130s, no dizziness; salt
intake down.
o 2) Dyslipidemia, exercises daily, still taking red rice yeast
extract, no muscle aches.
o 3) COPD, using inhaler PRN, wheeze reduced w/recent
jogging.
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Common E/M Service Documentation Errors –
Exam
•
•
Understand the difference between “Expanded ProblemFocused (EPF)” and “Detailed” examination under
1995/1997 guideline requirements.
The difference is not the number of systems examined. Two
to seven systems are required for both examinations.
o The difference is the detail in which the examined
systems are described.
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Common E/M Service Documentation Errors –
Exam
•
•
Always examine the system(s) related to the presenting
problem and do not describe it as “normal” or “negative.”
o Use “normal,” “negative” and “WNL” notations only to
describe unaffected or asymptomatic organ systems.
Code the physical examination considering the clinical
circumstances of the encounter.
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Common E/M Service Documentation Errors –
Exam
•
•
Avoid documenting exam elements that are unrelated
to the presenting problem.
Documenting problem lists with no diagnoses are
suggested, or else the principal diagnosis is not spelled
out clearly.
34
Common E/M Service Documentation Errors –
Counseling & Coordination of Care (Time)
•
The documentation does not support the requirement
that at least 50% of the visit was devoted to counseling
and/or coordination of care.
o Clinician notes she spent “around 20 minutes,” or
“approximately 35” minutes with the patient.
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Counseling & Coordination of Care (Time)
•
•
The document doesn’t adequately detail the nature of the
counseling and/or coordination of care.
Counseling with a patient and/or family in one or more of
these areas:
o Diagnostic test results, impressions and/or
recommendations.
o Prognosis; Risks and benefits of treatment options
o Instructions for treatment or follow-up
o Importance of compliance with treatment options
o Risk factor reduction
o Patient and family education
36
Common E/M Service Documentation Errors –
Cloning or Excessive Documentation
•
The copy and paste, or “cloning,” of the medical records is
on the OIG Work Plan for 2012
o Cloning of documentation will be considered
misrepresentation of the medical necessity requirement
for coverage of services.
o Cloning also occurs when medical documentation is
exactly the same from beneficiary to beneficiary or from
visit to visit.
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Common E/M Service Documentation Errors –
Cloning or Excessive Documentation
•
The record must be detailed enough to provide
comprehensive clinical data to facilitate continuity of care,
and it should be concise and pertinent to the current
encounter.
o Notes using EMR templates can contain pages of useless
information, or “fluff.”
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Common E/M Service Documentation Errors –
Cloning or Excessive Documentation
•
•
For example, a complete past, family and social history
(PFSH) is not required for every patient encounter.
o Often, this information is carried over from a previous
visit and it has no relevance for the patient’s presenting
problem.
Many EMR generated notes are too lengthy and contain
much more information than needed.
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Common E/M Service Documentation Errors –
Cloning or Excessive Documentation
•
The only time previously populated data should be brought
forward is when the information is pertinent to the current
encounter.
o
o
For example, it is not medically necessary to document a
comprehensive history on the same patient seen two or three weeks
prior.
Unfortunately, what some EMRs offer is to copy over of all previous
history data, or none.
40
Agenda
• Describe the nuisances of EM Coding and Documentation and
how this impacts the reimbursement of Medical Practices.
• Identify the rules and interpretation for proper usage of
Modifiers, including the new -X{EPSU} modifier that supplement
Modifier 59.
• Identify common reason for claim denials and how to avoid
these issues in your practice.
• Describe the Medicare’s Value Based Modifier and how it will
impact reimbursement.
41
Revisions to Modifier 59
•
•
•
The -59 modifier is the most widely used HCPCS modifier.
Modifier -59 can be broadly applied.
Some providers incorrectly consider it to be the “modifier to use to
bypass (NCCI).” This modifier is associated with considerable
abuse and high levels of manual audit activity; leading to reviews,
appeals and even civil fraud and abuse cases.
42
Revisions to Modifier 59
The primary issue associated with the -59 modifier
is that it is defined for use in a wide variety of
circumstances, such as to identify:
• Different encounters;
• Different anatomic sites; and
• Distinct services.
43
Revisions to Modifier 59
The -59 modifier is
• Infrequently (and usually correctly) used to identify a separate
encounter;
• Less commonly (and less correctly) used to define a separate
anatomic site; and
• More commonly (and frequently incorrectly) used to define a
distinct service.
44
Revisions to Modifier 59
CMS released CR8863 that establishes four new
HCPCS modifiers (referred to collectively as -X{EPSU}
modifiers) to define specific subsets of the -59
modifier:
•
•
•
•
XE Separate encounter
XS Separate structure
XP Separate practitioner
XU Unusual non-overlapping service
45
Revisions to Modifier 59
While CMS will continue to recognize the -59 modifier
in many instances, it may selectively require a more
specific - X{EPSU} modifier for billing certain codes at
high risk for incorrect billing.
• This will impact and change the NCCI Coding Edits.
• These modifiers are valid even before national edits are in place.
46
Revisions to Modifier 59
Examples of the use of the new modifiers;
please note CMS has not published specific
examples.
• XE - Separate Encounter: The patient receives an
outpatient infusion of antibiotics (CPT code 96365) at 8:00
AM, leaves the facility and returns at 8:00 PM for another
infusion of the antibiotics. The second line item 96365 would
require the -XE modifier.
47
Revisions to Modifier 59 Examples continued:
• XS - Separate Structure: A skin lesion of the arm was destroyed
via laser surgery and reported with CPT code 17000 (Destruction
(e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery,
surgical curettement), premalignant lesions (e.g., actinic
keratoses); and another lesion is biopsied on the leg and
reported with CPT code 11100 (Biopsy of skin, subcutaneous
tissue and/or mucous membrane including simple closure,
unless otherwise listed; single lesion). CPT code 11100 would
require the modifier - XS.
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Revisions to Modifier 59
Examples continued:
• XP - Separate Practitioner (for physician reporting): A
laparoscopic hernia repair (CPT code 49650) was
performed in the morning by surgeon A; later in the day
the patient developed acute abdominal pain and a
laparoscopic appendectomy (CPT code 44970) was
performed by surgeon B. The -XP modifier would be
applied to CPT code 44970.
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Revisions to Modifier 59
Examples continued:
• XU - Unusual non-overlapping service: Two separate lesions
are present that are within the same code set, and are
excised separately - i.e. a 4 cm. lipoma is excised on the
upper thigh (CPT code 27337 - excision tumor soft tissue
thigh/knee subcutaneous greater than 3 cm) and a
separate lipoma excised on the lower leg (CPT code 27327
- excision tumor soft tissue thigh/knee subcutaneous less
than 3 cm). The -XU modifier would be applied to code
27327.
50
Advanced Care Planning
New E/M Section created to report Advanced Care
Planning
• Services provide counseling and discussions on advance care
directives.
• Requires a Face-to-face encounter, but does not require the patient to
be present.
• Time based
• No active medical management
Invalid by Medicare as another code is used for the
reporting and payment of these services.
51
Advanced Care Planning
CPT Code 99497 Advanced care planning including
the explanation and discussion of advance directives
such as standard forms (with completion of such
forms, when performed), by the physician or other
qualified health care professional; first 30 minutes,
face-to-face with the patient, family member(s), and or
surrogate
• +99498 each additional 30 minutes (List separately in addition to code
for primary procedure)
52
Advanced Care Planning
• WSMA Resources
o http://www.wsma.org/washington-end-of-life-consensuscoalition
o Polst
o Advance Directives
o End of Life Coalition
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Agenda
• Describe the nuisances of EM Coding and Documentation and
how this impacts the reimbursement of Medical Practices.
• Identify the rules and interpretation for proper usage of
Modifiers, including the new -X{EPSU} modifier that supplement
Modifier 59.
• Identify common reason for claim denials and how to avoid
these issues in your practice.
• Describe the Medicare’s Value Based Modifier and how it will
impact reimbursement.
54
Are You Always Right? Can You Prove It?
Common criteria supporting code decisions
can be problematic
Faulty assumptions
• This is what I learned at a seminar/from an article in a well
known coding magazine.
• This was the manufacturer’s recommendation on how to
code it.
• That is what was recommended in a carrier
newsletter/carrier
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The Fundamental Coding Rule
•
•
Coding is a language and the code set rules require
that we all use the same words.
Each carrier has its own dialect. The codes can mean
different things to different carriers even when the
meaning is contrary to the description.
56
Claim Denial Trends
On a broader scale, research by the American
Medical Association (AMA) indicates that claim
denials dropped by 47% in 2013 after a sharp
increase in 2012 among most commercial health
insurers.
• Overall, the denial rate for commercial health insurers
decreased from 3.48% in 2012 to 1.82% in 2013.
• Among all insurers last year, Medicare had the highest denial
rate at 4.92%, while Cigna had the lowest denial rate at .54%.57
Claim Denial Trends
Relatively comparable to the AMA’s findings
are recent figures from the Medical Group
Management Association (MGMA).
• The percentage of claims denied on first submission is 3.8%,
according to MGMA’s most recent study, “Cost Survey
Report: 2013 Report Based on 2012 Data.”
• According to an estimate by the Center for Medicare and
Medicaid Services, claim denial rates could skyrocket by
100% to 200% in the early stages of coding with ICD-10.
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Claim Denials
•
•
Rejected claims can be a major drain on revenue.
According to the Medical Group Management Association
(MGMA), most practices spend an average of $25 to $30
each time they resubmit a corrected claim, which can
amount to thousands of dollars each year.
Practices that never bother to resubmit, however, leave far
more money on the table.
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THE POTENTIAL FINANCIAL IMPACT OF DENIALS*
Denied claims per physician per month 44
Rework cost per claim $25
Rework cost per month $1,100
Annual rework cost $13,200
• *This example assumes 370 visits per month, one claim line
per claim, and a denial rate of 12 percent.
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Common Claim Errors – Due to Registration
1. Incorrect and/or incomplete patient identifier
information (e.g., name spelled incorrectly; date
of birth or soc. sec. number doesn’t match;
subscriber number missing or invalid; insured
group number missing or invalid)
• Solution: Verify patient demographic and insurance
information at EVERY visit. Ask permission to photocopy the
patient’s state-issued identification (passport, drivers license,
etc.) and insurance card, so that you are sure to have the
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proper spelling, group numbers, etc., on hand.
Common Claim Errors– Due to Registration
2. Coverage terminated
• Solution: Verify insurance benefits prior to services being
rendered.
3. Services non-covered/Require prior
authorization or precertification
• Solution: You should contact the patient’s insurance and
confirm coverage prior to services being rendered. Patient’s will
be angry if you bill a patient for non-covered charges without
making them aware that they may be responsible for the
charges before their procedure.
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5 Common Documentation Errors
Lack of Notes:
• Every conversation the physician has between themselves
and the patient regarding, care, treatment, preventatives
and testing should be documented in the chart.
Inadequate history taking:
• Physicians need to take the necessary steps of interviewing
patients about their past medical history, allergies, drug
use, family history and names of other doctors that are
treating them.
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5 Common Documentation Errors
Fields left blank
• If the question was answered, even with a negative or
unknown answer this should be made known in the
medical record. For instance if the patient has no known
drug allergies, instead of just leaving the drug allergies
section blank, NKDA should be recorded in the field.
Careless Handwriting
Medication Problems:
• Prescriptions and refills must be adequately documented.
64
Claim Denials
• Medicare and many private payers often reject claims for
services deemed “not medically necessary.”
o In some cases, the diagnosis does not align with the
service provided, or the procedure/service is covered
only at certain frequencies.
o Either way, the quick fix is to confirm insurance
coverage and authorizations before each patient visit.
65
Claim Denials
• Misused modifiers are another common culprit.
o Modifier 25, for example, applies only to a “significant,
separately identifiable evaluation and management
service” by the same physician during the same visit.
o “Clinicians often depend on the billing staff to know
when a modifier is required, but sometimes they don’t
have the clinical expertise to differentiate between
modifiers. Training is the key to avoiding this
predicament.
66
Claim Denials
• Claims containing coding errors related to the place of
service are also commonly rejected.
• Many errors occur when the billing staff is not sure where
the service was rendered. Especially in this day and age of
changing entities.
• Confusion over primary and secondary insurance is also a
problem.
• Secondary payers will generally deny a claim if it is
submitted without a primary explanation of benefit.
67
Claim Denials
•
•
•
•
•
A duplicate claim was submitted when a practice hasn’t
received reimbursement.
A patient hasn’t met the deductible for the calendar year.
Services are bundled and the provider receives on
combined payment.
The benefits have been exceeded.
Deficient claims information.
68
Steps to Resolve Denials
•
In short, to maximize reimbursement, medical practices
should understand their payer policies, verify insurance
information, identify common scenarios for claims
issues, and investigate remarks on remittance advice
notices to prevent repeat denials.
69
Steps to Resolve Denials
Streamlining front office administrative tasks
•
•
•
•
•
•
Scheduling & appointments
Preparing forms
Keeping information organized and easily accessible
Creating charts
Collecting payments
Verifying insurance coverage and reimbursements
70
Steps to Resolve Denials
Billing
• Billing tasks
o Each lost or incomplete charge slip represents significant loss of revenue.
Additionally, hours of staff time is spent each day entering charge slips and
tracking down missing information.
•
•
•
•
Assigning proper diagnosis & billing codes
Payor & patient billing
Claims management
Accounts receivable
71
Critical actions for understanding and preventing
claim denials.
•
•
Look to see what improper payments were found by various
entities:
o OIG reports: www.oig.hhs.gov/reports.html
o CERT reports
o RACs www.cms.hhs.gov/cert
Conduct an internal assessment to identify if you are in
compliance with Medicare rules.
72
Critical actions for understanding and preventing
claim denials.
•
Monitor activities being conducted by Recovery Audit
Contractor (RAC) audits
o RACs required to post information on areas being
audited.
o Information also includes information on regulations and
guidance that support the audits.
73
Critical actions for understanding and preventing
claim denials.
•
Insurer Billing Guides/Provider Manuals
o
•
Access to individual insurers policies can vary and sites can
be difficult to search.
o
o
o
•
The nature of healthcare requires practices to well versed in payer
policies and guidelines.
Administrative Guidelines
Clinical Policies or Guidelines
Reimbursement Policies
Carrier Newsletters
o
Provides updates monthly/quarterly
74
Critical actions for understanding and preventing
claim denials.
•
Stay Informed on Payment Policies
o Incorporate payment policies affecting code assignment
in your coding policies and procedures.
o Maintain a copy of the provider bulletin that addresses
this policy with your coding policies and procedures.
75
Applying Coding Rules: Getting Paid Right!
Critical actions for understanding and preventing
claim denials.
Choose your tools
•
•
•
You can tackle denials with high-tech tools or with oldfashioned paper.
A practice that uses paper charts can still use a
computerized claims scrubber that checks claims before
they're submitted.
Practices can also use other software solutions:
o Coding Selection Software
o Online Claim Check Tools
76
Critical actions for understanding and preventing
claim denials.
Appeal denials thoroughly support and
document your argument.
• You can obtain additional supportive documentation through
the various sources such as:
o AMA CPT Manual, CPT Assistant
o National medical specialty societies, state medical
associations.
o Centers for Medicare and Medicaid Services (CMS) to
substantiate the physician’s service.
77
Critical actions for understanding and preventing
claim denials.
• Prepare an appeal letter that includes all the relevant data to
identify the claim.
o Review Coding Guidance, Coding Polices, and a Payer
policies.
o Forward all relevant documentation to all involved parties,
including the patient.
78
Critical actions for understanding and preventing
claim denials.
• Tell the insurer what you want first
o Reconsideration, review or re-evaluation, comparison with
other claims.
o The dollar amount you are requesting and why you believe
that amount to be fair.
• Explain your justification with documentation
o Provide supporting documentation.
o Request Insurer to provide justification of denial.
79
Tips for Keeping Consistent
• Ensure Consistent Training
o Provide all coders with the same education and training; roll
out information on updates to all staff at the same time
• Audit to Identify Inconsistencies
o Conduct regular audits or reviews; address inconsistencies
and errors with focused training
• Check Educational Sources
o Monitor the sources staff use to obtain coding advice;
ensure all coders use credible, official sources for guidance
80
Tips for Keeping Consistent
• Keep Cheat Sheets Current
o Ensure staff's personal "cheat sheets" contain up-to-date and accurate
information; consider creating authorized sheets for the facility's coding
manual
• Gather Staff for Discussions
o Use periodic staff meetings to discuss common questions and relay
consistent advice the entire team can use
• Promote Open Communication, Centralize Answers
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Agenda
• Describe the nuisances of EM Coding and Documentation and
how this impacts the reimbursement of Medical Practices.
• Identify the rules and interpretation for proper usage of
Modifiers, including the new -X{EPSU} modifier that supplement
Modifier 59.
• Identify common reason for claim denials and how to avoid
these issues in your practice.
• Describe the Medicare’s Value Based Modifier and how it will
impact reimbursement.
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Value-Based Modifier (VBM)
VBM assesses both quality of care furnished and
the cost of that care under the Medicare
Physician Fee Schedule.
• Begin phase-in of VBM in 2015, phase-in complete by 2017.
• Implementation of the VBM is based on participation in
Physician Quality Reporting System.
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Value-Based Modifier (VBM)
• Beginning January 1, 2016, the Value Modifier will be applied to
physician payments under the Medicare PFS for physicians in
TINs with 10 or more eligible professionals, provided that at least
one physician submitted a Medicare claim during 2014 under
the TIN. CY 2014 is the performance period for the Value
Modifier that will be applied in 2016.
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Value-Based Modifier (VBM)
• Beginning January 1, 2017, the Value Modifier will be applied to
physician payments under the Medicare PFS for physician solo
practitioners and physicians in groups with two or more eligible
professionals, as identified by their TIN. CY 2015 is the
performance period for the Value Modifier that will be applied
in 2017.
• CMS provides specific policies through rulemaking regarding
application of the Value Modifier to TINs participating in
Medicare Shared Savings Program ACOs, Pioneer ACOs, the
CPC initiative, and other similar initiatives.
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CY 2017 VM Payment Adjustment Amounts for
Groups with 2-9 EPs and Solo Practitioners
Cost/Quality
Low quality
Average quality
High quality
Low cost
+0.0%
+1.0x*
+2.0x*
Average cost
+0.0%
+0.0%
+1.0x*
High cost
+0.0%
+0.0%
+0.0%
* Groups and solo practitioners are eligible for an additional +1.0x if
reporting measures and average beneficiary risk scores are in the top
25% of all beneficiary risk scores, where ‘x’ represents the upward
payment adjustment factor
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CY 2017 VM Payment Adjustment Amounts for
Groups with 10+ EPs
Cost/Quality
Low quality
Average quality
High quality
Low cost
+0.0%
+2.0x*
+4.0x*
Average cost
-2.0%
+0.0%
+2.0x*
High cost
-4.0%
-2.0%
+0.0%
Groups are eligible for an additional +1.0x if reporting measures and
average beneficiary risk scores are in the top 25% of all beneficiary risk
scores, where ‘x’ represents the upward payment adjustment factor.
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Value-Based Payment Modifier
Quality Measures
• CMS calculates the quality composite score based on a TIN’s
performance on six equally-weighted quality domains:
o
o
o
o
o
o
1) Clinical Process/Effectiveness
2) Patient and Family Engagement
3) Population/Public Health
4) Patient Safety
5) Care Coordination
6) Efficient Use of Healthcare Resources
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2015 Value-Based Payment Modifier results
The VBPM results indicate that 1,010 groups
are subject to the VBPM in 2015.
• 319 of these groups will receive an automatic -1% penalty
because they did not register to report for PQRS as a group
via registry or web interface or elect the administrative
claims group reporting option under PQRS in 2013.
89
2015 Value-Based Payment Modifier results
The VBPM results indicate that 1,010 groups
are subject to the VBPM in 2015.
• In addition, out of the remaining 691 groups that did
satisfactorily participate in PQRS or report as a group via
the PQRS administrative claims reporting option:
• 127 groups elected to have CMS calculate the VBPM using
the quality-tiering methodology that will be mandatory in
2017.
90
2015 Value-Based Payment Modifier results
The VBPM results indicate that 1,010 groups
are subject to the VBPM in 2015.
• Of these 127 groups:
o 14 received an upward adjustment to their 2015 payments
o 11 received a penalty of -0.5% or -1.0% to their 2015 payments
o 102 received no adjustments to their 2015 payments (21 of which did
not have enough cost or quality data from 2013 for CMS to calculate
the VBPM).
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Quality-Tiering
The quality-tiering analysis under the VBPM
provides an upward, neutral or downward
payment adjustment based on the group’s
performance on quality and cost measures as
compared with national benchmark
performance data in these areas.
• For the 2017 VBPM, which is based on 2015 performance,
quality-tiering is mandatory in 2017 for all physicians.
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Quality-Tiering
• In 2017, groups with 2-9 EPs and solo practitioners will be
held harmless from any downward payment adjustments
while groups with 10+ EPs may see up to a -4% payment
adjustment.
• Upward adjustments, or incentives earned under qualitytiering, will be established by CMS after the performance
period has ended.
• Incentive payments will be based on the aggregate
amount of downward payment adjustments determined
under budget neutrality requirements.
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CMS Goals
•
•
“Our goal is to have 85% of all Medicare fee-for-service
payments tied to quality or value by 2016, and 90% by 2018.”
“Our target is to have 30% of Medicare payments tied to
quality or value through alternative payment models by the
end of 2016, and 50% of payments by the end of 2018.”
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Medicare Physician Feedback and Value
Modifier Program
“Supports the transformation of Medicare from
a passive payer to an active purchaser of
higher quality, more efficient health care.”
• Four interrelated parts:
o
o
o
o
PQRS
Physician Compare
QRUR
Value Modifier
• Remains in place through 2018
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Physician Quality Reporting System
NPI fails to report PQRS in this year NPI will be
penalized in this year
•
•
•
•
2013-2015 (-1.5%)
2014-2016 (-2.0%)
2015-2017 (-2.0%)
2016-2018 (-2.0%)
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Quality and Resource Use Reports (QRUR)
•
•
•
Through its Physician Feedback Program, the Centers for
Medicare & Medicaid Services (CMS) distributes Quality
Resource and Use Reports (QRURs) to physicians to provide
detailed information about their performance on the quality
and cost of care delivered to Medicare fee-for-service
patients.
CMS sends QRURs to solo physicians and groups based on
their Tax Identification Numbers (TIN).
Each report includes performance information on PQRS
quality measures, claims-based outcome measures, and
claims-based cost measures and compares performance to
97
similar peer groups.
Quality and Resource Use Reports (QRUR)
•
•
CMS uses the quality and cost data to calculate payment
bonuses and penalties under the Value-based Payment
Modifier Program—and eventually will determine financial
bonuses and penalties under the new Merit-Based Incentive
Payment System (see more below).
Use your QRUR to your advantage to inform care delivery to
receive bonus payments and avoid penalties.
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Quality and Resource Use Reports (QRUR)
•
Assistance with understanding QRUR reports!
o Qualis Health is one of the nation's leading population
healthcare consulting organizations, partnering with our
clients to improve care for millions of Americans every
day. We work with public and private sector clients to
advance the quality, efficiency and value of healthcare.
o They offer assistance to practices with Interpretation
and Quality Improvement.
o http://www.qualishealth.org/
99
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
•
This bipartisan legislation permanently repeals the
sustainable growth rate (SGR) formula and stabilizes
Medicare payments for physician services with positive
updates from July 1, 2015, through the end of 2019, and
again in 2026 and beyond.
100
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
The SGR formula is permanently repealed,
avoiding the 21.2 percent payment cut.
• Positive updates for 4 1/2 years.
• The law includes annual updates of: 0 percent for January
2015 through June 2015;
• 0.5 percent for July 2015 through 2019; and 0 percent for
2020 through 2025.
101
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 11410
• For 2026 and beyond, the update will be 0.75 percent for
eligible alternative payment model (APM) participants; and
0.25 percent for all others.
• The Medicare Payment Advisory Commission (MedPAC) must
report to Congress by July 1, 2019, with “recommendations for
any future payment updates for professional services under
such program to ensure adequate access to care is
maintained by Medicare beneficiaries.”
102
Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA), H.R. 2, Pub. Law 114-10
•
It replaces Medicare’s multiple quality reporting programs
with a new single Merit-based Incentive Payment System
(MIPS) program that makes it easier for physicians to earn
rewards for providing high-quality, high-value health care,
and it supports and rewards physicians for participating in
new payment and delivery models.
103
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
The “Merit-based Incentive Payment System”
(MIPS) quality program:
• Beginning in 2019, MACRA provides bonuses for physicians
who score well in the MIPS
• A new pay-for-performance program under the current
Medicare fee-for-service payment system.
104
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
• Current penalties under the Physician Quality Reporting
System (PQRS), Electronic Health Records/Meaningful Use
(MU), and the value-based payment modifier (VBM) will
end at the close of 2018.
• In 2019, the MIPS program will become the only Medicare
quality reporting program.
105
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
• Performance and “composite scores” under the MIPS will
be based upon four categories:
o
o
o
o
quality (PQRS/30 percent);
resource use (VBM/30 percent);
MU (25 percent);
and clinical practice improvement activities (15 percent).
106
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), H.R. 2, Pub. Law 114-10
• These will build and improve upon the current quality
measures and concepts in PQRS, MU, and VBM.
• Physicians are specifically encouraged to report quality
measures through certified EHR technology or qualified
clinical data registries.
• Participation in a qualified clinical data registry will also
qualify as a clinical practice improvement activity.
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State Resources
•
•
Washington State Department of Health http://www.doh.wa.gov/Home.aspx
Office of the Insurance Commissioner http://www.insurance.wa.gov/
108
Federal Resources
•
•
CMS Online Manual System http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/index.html
CMS Conditions of Participation (CoPs) and Conditions
for Coverage (CfCs) http://www.cms.gov/Regulations-andGuidance/Legislation/CFCsAndCoPs/index.html
109
Other Resources
Coding Networks
Medical Association/Specialty Society
• Advocacy on your behalf
• Track common ongoing issues
• Work with all parties to resolve issues
AMA Resources
• CPT Guidelines
• CPT Network
• CPT Assistant
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Resources
•
•
•
Emergency Medical Treatment & Labor Act (EMTALA) http://www.cms.gov/Regulations-andGuidance/Legislation/EMTALA/index.html
National Correct Coding Initiative Edits http://www.cms.gov/Medicare/Coding/NationalCorrectCo
dInitEd/index.html
Medicare Learning Network (MLN) http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNGenInfo/index.html
111
Resources
•
•
U.S. Department of Health & Human Services http://www.hhs.gov/
Office of Inspector General - http://oig.hhs.gov/
112
Thank You
For more information, contact
Michelle Lott, CPC, CPMA
[email protected]
206.441.9762