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					CODING FOR
 SUCCESS
   2010:
   Basics of the
     Business
Coding Conventions
   Consultations
Signatures and Such
Re-enrollment for
    Referrals
  ACP Northern
   Chapter San
    Francisco
November 21, 2010
           We Will Discuss
• Coding Challenges
   –   Consultations for Specialists
   –   E & M Situations
   –   Modifiers for IM
   –   Coding by Teaching Physicians
• Current Medicare Problems
   – Signatures and Legibility
   – Enrollment / Revalidation
   – Documentation Dilemmas
• Responding to Reviews
   – Respond to Record Requests
   – Appeal Process
• Looking to the Future:
   – Primary Care and Other Bonuses
     ICD-10 is Coming
   – Other
President Johnson signing the Medicare Bill-1965
  CONSULTATION CODES
• Maintained in 2010 CPT for
  some non-Medicare
  insurance
   – ? effect private insurance
     & Medicaid
• Distinguish consult from
   – Transfer of care
   – Co-management
   – Patient request 2nd opinion
       CONSULTATION
• As of 1/1/2010: Consultations no longer
  reimbursed by Medicare…here is how to
  code for services formerly called consult:
   – Use Initial E&M admission visits codes for
     initial inpatient hospital & SNF services
   – Can have as many initial inpatient
     services as needed if different specialty
   – Regular follow up codes for hosp / SNF-NF
   – Regular office initial & follow up codes
   – All E&M services follow E&M guidelines
• Principal MD of record uses a modifier: AI
      CONSULTATION
• Financial Offset to Consultation Codes
  – Work value RVUs for new or established
    office visits increased by 6%
  – Work value RVUs for hospital and facility
    visits increased by 2%
  – Increased bundled global payments for 10
    and 90 day surgical or interventional
    procedures to recognize increased office
    or hospital visit payments
    EMERGENCY ROOM
        VISITS
• ED Physician bills ED codes
• Attending MD admits patient from
  ER, use hospital admit codes
• Attending doc adds modifier AI
• Docs called to see patient in ED
  bill regular ED codes
• If seen by 2nd physician (or by a
  specialist) code office visit if not
  admitted—because patient is an
  outpatient
HOSPITAL OBSERVATION
• Initial observation codes only for doctor who
  ―admitted‖ to obs svs (modifier: AI)
   – Must have full timed and dated obs notes
   – One payment for all services that day
   – All others seeing patient bill office or other
     outpatient (initial or subsequent)
   – Only physician who ―admitted‖ patient to
     hospital observation may bill initial obs care.
• Observation after surgical procedure
   – Part of surgical global service in most cases
   – Exception if Modifiers 24, 25, 57 apply and all
     observation data applies
   – Decision for surgery—bill office/ other outpatient
     services if in ED or initial hosp if admitted
  INITIAL HOSP ADMISSION
          SVCS
• Initial hosp admission code if seen in
  ED then admitted---all services done
  same day one code
• All docs use initial hosp admission
  codes but attending of record uses
  modifier AI
• Physician performing level 5 visit in
  office several days prior to admission,
  unless complex admission needed &
  completely documented, bill full office
  visit then lowest level hosp visit
IF MEDICARE SECONDARY
     • Can bill Primary Insurance
       with Consultation Codes
       but if sending to Medicare
       – Use regular visit codes
       – Show amount of money paid
         from Primary Insurer
     • Can bill Primary Insurance
       with regular visit codes
       and bill Medicare with
       same codes
HIGHEST LEVEL E&M CODES

• To bill highest level visit
 codes, services furnished must
 meet the definition of the code
 (e.g., to bill a Level 5 new
 patient visit, the history must
 meet CPT’s definition of a
 comprehensive history).
• Comp. exam may be a
  complete single system exam
  (e.g. cardiac, respiratory,
  psychiatric) or a complete
  multi-system exam BUT MUST BE COMPLETE
HIGHEST LEVEL E&M CODES
• Comp. history must include a review of all
  the systems and a complete past (medical
  and surgical) family & social history
  obtained at that visit.
• For established patient, it is acceptable for
  a physician to review the existing record
  and update it to reflect only changes in the
  patient’s medical, family, and social history
  from the last encounter, but must review
  the entire history for it to be considered a
  comprehensive history.
 COMPONENTS OF (E&M)
SERVICES: Back to Basics
• HISTORY    • COUNSELING
             • COORDINATION
• EXAM         OF CARE
             • NATURE OF PRESENTING
• DECISION     PROB.
  MAKING
             • TIME
History of Present Review of     Past, Family, and/or Type of History
Illness (HPI)     Systems (ROS) Social History (PFSH)


Brief               N/A             N/A              Problem
                                                     Focused
Brief             Problem           N/A            Exp. Problem
                  Pertinent                          Focused

Extended         Extended        Pertinent            Detailed

Extended        Complete         Complete           Comprehen.



    To qualify for a given level of history
        all three levels must be met.
             EXAM
         DOCUMENTATION
•   PROBLEM FOCUSED   • Limited exam of affected
                        body area /organ sys.

• EXPANDED PROBLEM • Limited exam affected
  FOCUSED            body area & symptomatic
                     related body areas

•   DETAILED          • Extended exam of
                        affected body area and
                        any other symptomatic or
                        related body area.
•   COMPREHENSIVE     • General multi-system …
                        ..Or complete single
                        system and symptomatic
                        or related body areas
 12 TYPES OF EXAMS
1.   MULTISYSTEM      7. HEME / LYMPHATIC
2.   CARDIOVASCULAR   8. MUSCULOSKETAL
3.   E.N.T.           9. NEUROLOGICAL
4.   OPHTHALMOLOGY    10 PSYCHIATRIC
5.   G.U. (Female)    11 RESPIRATORY
6.   G.U. (Male)      12 SKIN


        ANY PHYSICIAN CAN BILL A
          MULTI-SYSTEM EXAM
        ANY PHYSICIAN CAN BILL A
          SINGLE SYSTEM EXAM
    BASICS OF DECISION
         MAKING
• The number of possible diagnoses and/or
  management options considered
• The amount and/or complexity of records,
  diagnostic tests, and information that must
  be obtained, reviewed, and analyzed
• The risk of significant complications,
  morbidity / mortality, and comorbidities,
  associated with the patient's presenting
  problem, the diagnostic procedures, and/or
  the possible management options
   DECISION MAKING CHART

Number of      Amount &      Risk of
Diagnoses or   Complexity    Complication\ Type of Decision
Management     of Data for   Morbidity or  Making
Options        Reviewed      Mortality
               Minimal or
Minimal                      Minimal       Straightforward
               none
Limited        Limited       Low           Low complexity
Multiple       Moderate      Moderate      Mod complexity
Extensive      Extensive     High          High complexity
        BASIC VISITS
• OFFICE VISITS: NEW • HOSPITAL VISITS:
   – 99201             INITIAL
   – 99202              – 99221
   – 99203              – 99222
   – 99204              – 99223
   – 99205           • HOSPITAL VISITS:
• OFFICE VISITS:       SUBSEQUENT
  SUBUBSEQUENT
                        – 99231 to 99233
   – 99211
   – 99212           • HOSPITAL DISCHARGE
   – 99213              – 99238
   – 99214              – 99230
   – 99215
       CRITICAL CARE
           CODES
• Critical care is the direct    •   The following services are
  delivery by a physician(s)         included in critical care
                                 •   Interpretation of cardiac
  of medical care for a              output measurements
  critically ill or critically   •   Chest x-rays
  injured patient. A critical    •   Pulse oximetry
  illness or injury acutely      •   Blood gases
  impairs one or more vital      •   Information data stored in
  organ systems such that            computers (eg, ECGs,
                                     blood pressures,
  there is a high probability        hematologic data)
  of imminent or life            •   Gastric intubation
  threatening deterioration      •   Temporary
  in the patient's condition         transcutaneous pacing
                                 •   Ventilator management
• 99291 – 1ST 30-74 MIN.         •   Vascular access
                                     procedures
• 99292 – ADD. 30 MIN
NURSING HOME VISITS
(Also Interm. & Long Term)
• INITIAL CARE     • SUBSEQUENT CARE
   – 99304           – 99307
   – 99305           – 99308
   – 99306           – 99309
                     – 99310

--99315 NURSING FACILITY D/C   30 MIN
--99316 NURSING FACILITY D/C >30 MIN
--99318 OTHER (ANNUAL) N. F. ASSESS.
    OTHER E&M MEDICAL
          VISITS
• HOSPITAL EMERGENCY ROOM
• HOSPITAL OBSERVATION
• HOSPITAL DISCHARGE
• HOME VISITS (NEW & ESTAB.)
• DOMICILLARY-REST HOME-
  CUSTODIAL CARE (NEW & ESTAB.)
• PROLONGED PHYSICIAN SVCS
• CARE PLAN OVERSIGHT
• ETC.
TEACHING PHYSICIAN
  REQUIREMENTS
     • INSTITUTIONS GET SOME
       ADDITIONAL PAYMENT FOR
       RESIDENTS AND FELLOWS
     • TEACHING PHYSICIANS MUST
       BE PRESENT FOR PRINCIPAL
       PORTION OF ALL PROCEDURES
     • TEACHING PHYSICIANS MUST
       EITHER BE PRESENT FOR OR
       PERSONALLY PERFORM &
       DOCUMENT SIGNIFICANT
       PORTIONS OF E&M VISITS IN
       ORDER TO BILL FOR THEM
     • SIGNATURES ALONE ON A
       CHART ARE NOT ENOUGH
   FINAL THOUGHTS ON
  CODING: Be Appropriate
• E&M code must be appropriate to service
• Time can be used if longer visits needed
  – Indicate time on progress notes when time used
  – Face to face, Psych, therapy, ICU, etc.
• Using modifiers improves reimbursement
  – Listed in Palmetto website (-25, -24, 22, 59, etc)
  – Learn the few that involve your practice
• Don’t overcode, but don’t undercode either
  – You are entitled to be paid for your service
  – You are not entitled fo be paid for your ego
• Learn the codes you actually use
• Make sure your billers know what you did
www.PalmettoGBA.com/J1B
                     Internal Medicine Clinical Example
                            Brief Physical Examination
                                    Number 1

Constitutional:      BP 130/70, P 72. Well-developed, well-nourished patient in no
                     acute distress. No fever.

HEENT:               Redness of conjunctiva, left greater than right, mild discharge
                     in left eye. No blurry vision.

                     Internal Medicine Clinical Example
                            Brief Physical Examination
                                    Number 2

Constitutional:      BP 120/180.

Back and extremities:      Pain from left shoulder to hand. Soft tissue swelling,
                    tenderness at elbow. Squeezing is painful. Able to raise and
                    lower, place behind body, but uncomfortable.
                  Internal Medicine Clinical Example
                          Brief Physical Examination
                                  Number 4

Constitutional:          BP 140/100.
Chest:            Bronchial-type breath sounds with scattered wheezes,
                  anteriorly and posteriorly. No evidence of E to A change.

Pharynx:          Clear

Cardiac:          Tones of good quality.

                  Internal Medicine Clinical Example
                          Brief Physical Examination
                                  Number 5

Constitutional:   BP 140/170, P 70, T 97.8.
Cardiac:          Regular and rhythmic.

Chest:            Clear.
Other:            No lymphadenopathy or hepatosplenomegaly.
                Internal Medicine Clinical Example
                   Detailed Physical Examination
                             Number 1

Constitutional:    BP 111/60, weight 151 and stable.
HEENT:            Unchanged and unremarkable.
Neck:             Supple. No JVD.
Cardiac:          Irregularly irregular.
Chest:            Clear, with diminished breath sounds except
                  for slight rales at the right base.
Abdomen:          Soft. Liver edge is 2 cm below the right costal
                  margin. No organomegaly or other masses.
                  Bowel sounds normal.
Extremities:      Trace edema.
Neurological:     Diminished strength diffusely. Deep tendon
                   reflexes hypoactive.
             Internal Medicine Clinical Example
                Detailed Physical Examination
                          Number 2

Constitutional: Patient is alert, but looks chronically ill and
                appears to be encephalopathic, BP 117/47, P
                80, R 23, T 97.8.
HEENT:          Conjunctiva pale.
Neck:           Supple, no JVD.
Heart:          Regular, no S3, S4, no gallops, rubs, murmurs.
Lungs:          Bilateral crackles, no wheezing.
Abdomen:        Soft, but tender in the left lower quadrant. No
                masses. Bowel sounds present, but decreased.
                No rebound.
Extremities: Minimal edema .
             Internal Medicine Clinical Example
                Detailed Physical Examination
                          Number 3

Constitutional: Weight 139, BP 150/74, P 72.
HEENT:          Eyes have normal range of motion, pupils
                equally reactive to light, slightly pale disks.
                Fundi show arteriolar narrowing. TMs
                normal.
Neck:           Supple, thyroid normal, mild kyphoscoliosis.
Chest:          Clear.
Cardiac:        Heart sounds normal. No carotid bruits.
                Radial and dorsalis pedis pulses 2+ bilaterally.
Abdomen:        Normal bowel sounds, soft, non-tender without
                hepatosplenomegaly.
Extremities:    Marked osteoarthritic changes, particularly of
                hands. Surgical scars over knees. No
                peripheral edema.
                  Internal Medicine Clinical Example
                    Comprehensive Physical Examination
                                   Number 1
Constitutional:   Patient can be aroused, but is sleepy and wants to curl up on
                  left side. BP 173/84, P 120, R 32 and mildly labored, T 36.1.
HEENT:            Normocephalic. Pupils equal, round, and react to light. Fundi
                  not well visualized, as patient is unable to cooperate well with
                  the exam. No obvious oral mucosal lesions. Uvula ascends in
                  midline. Patient wears dentures, both upper and lower.
Neck:             Supple. Carotids are 2+/2+ with adequate upstroke. Thyroid
                  is not enlarged. No supraclavicular or cervical adenopathy.
                  Range of motion appears to be reasonably normal. No neck
                  masses palpable.
Chest:            Diminished breath sounds. Mild prolongation of expiratory
                  phase with a small amount of wheezing anteriorly. There are
                  a few rales in the bases.
Cardiac:          Irregularly irregular rhythm with a variable first heart sound
                  and normal second heart sound. Grade 3/6 holosystolic
                  murmur heard best at the apex, but also heard in the lower
                  left sternal border and to a lesser extent up by the second left
                  and right intercostal space. The precordium is not
                  hyperdynamic. There is mild increase in JVD and positive
                  hepatojugular reflux.
Breasts:          Small, atrophic, and free from mass.
Abdomen:          Obese. Liver and spleen not enlarged. No guarding or
                  rebound. No other abnormality seen. Bowel sounds active.
Rectal:           Exam revealed a small amount of brown stool that was
                  strongly heme positive.
Extremities:      Free from clubbing or cyanosis. Massive edema in both feet,
                  extending up to the knees, with 2 to 3+ pitting in the dorsum of
                  both feet. Plantars are downgoing.
Neurological:     Speech is okay, although doesn’t want to talk much. Mood is
                  neutral. Affect is appropriate. Face is symmetrical. Cranial
                  nerves appear to be otherwise intact. Weaker on left
                  compared to right.
            Internal Medicine Clinical Example
          Low Complexity Medical Decision Making
                        Number 1

Laboratory:
INR 3.1
Impression:
1. History of thrombophlebitis with pulmonary embolism.
2. Hyperlipidemia.
3. Hypertension.
Plan:
1. Indefinite anticoagulation due to family history of
   thromboembolic disease. No change in present Coumadin
   dosage.
2. Continue Lipitor.
3. Recheck one month.
            Internal Medicine Clinical Example
          Low Complexity Medical Decision Making
                        Number 2

Impression:
1. COPD.
2. Hypertension, etiology unknown, possibly due to quinine.

Plan:
1. Continue use of Combivent meter dose inhaler.
2. Discontinue quinine for several days, then recheck blood
   pressure. If blood pressure remains elevated, will treat
   appropriately at that time.
            Internal Medicine Clinical Example
        Moderate Complexity Medical Decision Making
                        Number 1

Laboratory:
CBC shows WBC 15.6, Hgb 14.7, Hct 42.7, platelet count
178,000. Sodium 142, potassium 4.2, chloride 103, bicarbonate
19, BUN 21, creatinine 1.7, glucose 149. Urinalysis shows
yellow turbid urine with nitrites, many WBCs and positive
esterase. Liver function tests normal.
Impression:
1. Urinary tract infection.
2. Vomiting, from UTI.
Plan:
1. Ciprofloxacin at 200 mg IV q 12 hours.
2. Obtain blood cultures. If negative, discharge patient back to
   nursing home on po medications.
Plan was carefully discussed with the patient who nodded
understanding, but could not verbalize due to aphasia.
            Internal Medicine Clinical Example
        Moderate Complexity Medical Decision Making
                        Number 2

Impression:
1. Atrial fibrillation, well-controlled ventricular response.
2. Dilated cardiomyopathy, with mild worsening symptoms of
   heart failure, as manifested by exercise intolerance.
3. History of possible Adriamycin toxicity.
Plan:
1. Refer to cardiologist for heart failure.
2. Patient to have dental extraction. Stop Coumadin four days
   prior to procedure, resume two days after.
            Internal Medicine Clinical Example
          High Complexity Medical Decision Making
                         Number 1

Laboratory:
Normal CPK and LDH. Chem-7 remarkable for glucose of
263. CBC shows WBC 7.8, Hgb 13.2, Hct 38.6.
EKG from emergency room shows slight T wave peaking in
lead V2 and V 3. A second EKG reveals that patient lost R
waves in V 2 and V 3 and now has Q waves. Normal rhythm,
normal sinus with rate of 50.
Impression:
1. Unstable angina, rule out myocardial infarction.
2. History of polymyalgia rheumatica.
3. Glucose intolerance, likely Type II diabetes precipitated by
   steroid use.
Plan:
1. Start Tridil, continue one aspirin daily and ß-blocker.
   Morphine as needed for pain.
2. Immediate cardiology consultation regarding further
   recommendations.
3. Check sedimentation rate; restart prednisone 10 mg daily.
               Internal Medicine Clinical Example
           High Complexity Medical Decision Making
                            Number 2
Laboratory:
CBC, Chem-17, and blood cultures X 2, urine culture, sputum
culture, EKG, and chest X-ray done on arrival in PCU. All
results pending.
Impression:
1. Biventricular CHF, with decompensation due to
                 noncompliance with medications.
2. Productive cough, probably pneumonia.
3. Aortic regurgitation.
Plan:
1. Patient admitted directly to PCU.
2. Rule out myocardial infarction.
3. Diurese with Lasix, place on nitroglycerin drip overnight for
   blood pressure control and to unload heart.
4. Nifedipine changed to amlodipine at 5 mg. one po qd.
   Consider ACE inhibitors after laboratory work obtained.
5. Start ceftriaxone 1 gm. IV qd for probable pneumonia.
6. Simplify medications as much as possible to encourage
   compliance.
7. Cover with thiamine 100 mg. IV x 1 due to alcoholism
   history and watch for signs of withdrawal.
Patient will need home health follow-up on discharge
             SIGNATURES
•     Handwritten signatures or initials
    –   Must be legible in all notes and orders
•     Electronic signatures:
    –   Digitized- an electronic image of an individual’s
        handwritten signature reproduced in its
        identical form using a pen tablet
    –   Electronic signatures usually contain date &
        timestamps and include printed statements,
        e.g., 'electronically signed by,' or 'verified/
        reviewed by,' followed by physician’s name &
        preferably a professional designation. Note:
        The responsibility and authorship related to
        the signature should be defined in the record
    –   Digital signature - an electronic method of a
        written signature typically generated by
        encrypted software that allows for sole usage
SIGNATURES: WHAT WE
    ARE FINDING
• Illegible, unrecognizable handwritten
  signatures or initials
• Unsigned ―typewritten‖ progress
  notes with a typed name only
• Unverified or unauthorized electronic
  signatures
• No indication of the rendering
  physician/practitioner
• Sometimes, no name of doctor,
  patient or office
       SIGNATURES
• CMS Rules for signatures
  unchanged but had not been
  enforced earlier
• Many times with teams of
  physicians, author of note is
  uncertain
• Various review organizations
  now are looking for legible
  signatures
  – If no signature, claim rejected
  – If illegible signature, claim
    rejected
 IF SIGNATURE IS AN
ILLEGIBLE SCRAWL…
    • Have an official signature
      page with name and
      signature
      OR
    • Send an attestation
      statement certifying that
      physician saw patient and
      wrote note on that date
ORDERING-/-REFERRING
RULES FOR MEDICARE
•   MD               Clin. Nurse Specialist
•   DO               Clin. Psychologist
•   Dental Surgery    Nurse Midwife
•   Dental Medicine Clin. Social Worker
•   Podiartist        Nurse Practitioner
•   Optometrist       Chiropractor
•   Physician Assistant
ORDERING PHYSICIAN
• Claims ordered / referred must have:
  – NPI of ordering provider
  – Number in PECOS system
  – Specialty as listed
• Grace Period
  – Initial: 10/5/09 to 12/31/10 warning
    message on remittance
  – ACA Reform: 6/04/10 and after:
    claim rejected if referring individual
    not in PECOS or MAC list
• CMS is not enforcing as yet---will
  enforce sometime before 1/1/11
  OTHER ENROLLMENT
• Revalidation of all physicians not
  already in PECOS (Provider
  Enrollment Chain Online System)
• Revalidation of some labs & IDTFs
• Need to update any changes within
  30 days – in PECOS or paper change
   – Address, phone, suite
   – New members in group
   – Other changes
• If no claims to Medicare in one year—
  physician is automatically disenrolled
  SOME 2010 CHANGES
• Cardiac Rehabilitation
  – Cardiac Rehab (93797 – 93798)
  – Intensive Cardiac Rehab (G0422 – G0423)
• Pulmonary Rehabilitation
  – For moderate to severe COPD (G0424)
• Kidney Disease Patient Education
  – Up to 6 sessions (G0420 – G0421)
  – For level 4 CKD (GFR 15-25 ml/min)
• Increased Reimbursement-Primary Care
  – Increased this year
  – More increases with ACA
  CHANGES IN MEDICARE
    REIMBURSEMENT
• Increases in reimbursement for
  cognitive services
• Decrease for imaging services
• More emphasis on primary care
• Decreases in surgical /
  procedural services
• Sustainable Growth Rate still in
  limbo
  – Need Congressional change
  – Unlikely until after elections
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       POTENTIALLY
    MISVALUED SERVICES
•   Site of service anomalies
•   Services with high volume growth
•   High intra-service work per unit time
•   New technologies – need pricing
•   Shifts from practice expense to work
•   Harvard valued codes (not studied)
•   Services often billed together
•   Multiple procedure payment reduction
•   Reduced tech component of CT-MR-PET
•   High cost supplies
  UP & COMING-ICD-10
• ICD-10 will start Oct 1, 2013
• In what ways is it different:
   – More granular—more coding
     specificity
   – 3 to 7 alpha and numeric digits
   – Thousands more codes than ICD-9
   – Some codes expanded, bilateral, etc
   – More inclusions and exclusions
   – More post-op complications
UP & COMING-ICD-10
• Injuries list by anatomical area, not
  by type of injury;
• Category restructuring and code
  reorganization will result in
  classification of certain diseases and
  disorders different from ICD-9-CM;
• Certain diseases reclassified to
  different chapters or sections
• New code definitions (e.g., definition
  of acute myocardial infarction is now
  4 weeks rather than 8 weeks)
UP & COMING-ICD-10
• The codes corresponding to current
  ICD-9-CM V codes and E codes will
  be incorporated into the main
  classification rather than separated
  into supplementary classifications
  as they were in ICD-9-CM.
• Other possible changes when the
  final version is adapted in 2013
   HOW TO DEAL WITH
 ICD-10…coming in 2013
• CMS, AMA and Specialty Societies will
  have massive education available
• CMS Contractors already planning
  changes in policies and claims and
  educational opportunities to prepare
• Keep following news as it comes out
• Buy ICD-10 manuals in 2012
• Various companies will offer templates
  and devices to teach changes
• Info on line: www.cms.gov/ICD-10