Boston Sports Medicine Symposium How to Maximize Reward & Minimize Risk in Your Orthopedic Practice

Billing and Coding: How do I do it? William Beach, MD Orthopaedic Research of Virginia

Conflict of Interest Statement  Fellowship Grants  Smith Nephew  Arthrex  Synthes  Share Holder  Tuckahoe Surgery Center & St. Mary’s ASC  Comp Recovery

“Welcome to the Game” The greatest threat to your practice and your success is government regulation! 2/11/11

Governmental Programs Recovery Audit Contractors (RAC) Medicare Administrative Contractors (MAC) Zone Program Integrity Contractors (ZPIC) Comprehensive Error Rate Testing (CERT) Reported 9:1 ROI for all programs

CMS and Extrapolation CMS receives 10,000 payment requests (bills)/minute All these submissions are housed electronically Audit Known billing errors at the outset Review these charts Extrapolate that error rate to your total visits!

Correct Coding – Painful but Important!  Medicare Fraud – intentional or unintentional, doesn’t matter  Based on what you should know, not what you may know (= at least, what I know)  5 years in prison and a $10,000 fine  For every occurrence  Plus interest  Disqualified from participation in Medicare  You cannot abdicate this responsibility to an assistant or EMR!!!! 2/11/11

My Approach to E&M Coding  Develop/acquire all the necessary paper tools to facilitate data collection and documentation  Define the expected/anticipated level of service (N3 (99203) and E3 (99213) or E4 (99214))  Understand the variations of the expected level of service  Count bullets (ignore useless terms – PF/Comp.)  Document the E&M service  Code the service  Develop – Define – Document (D³) & KEEP IT SIMPLE 2/11/11

Templates – A MUST! History, Physical Exam and Medical Decision Making – use a template to assure all elements are addressed Bubble forms are the ultimate template Aid in efficiency Increase patient work time Increase team encounter time DECREASE physician encounter time!

The Key Components/PEARLS  Chief Complaint and History  Physical Exam  Medical Decision Making  Every medical record must have each of these documented or referenced for audit purposes  Reimbursement is based on the Lowest Level of service for these required key components* (3/3 for New Pt, 2/3 for Established Pt.) 2/11/11

New Patient History

Physical Exam Bullets - TRIM

New Patient Physical Exam body part 1 body part 2 body parts 4 body parts 4 body parts 6/9/2016

MDM New Patient

Established Patient History Bullets (Copy and Paste) 6/9/2016

Physical Exam – PASS ON THE AUDIT

Established Patient MDM

E&M Expectation  Level 3 New patient visit  History = 5, PE* (2 body parts) = 3, MDM = 3  Level 4 Established patient requires:  Level 4 or higher historyPass on the PE  Level 4 MDM*  Data = 3 points OR2 Diagnoses  Level 4 Plan/Risk =  Prescription  Injection  Surgery  * Rate limiting key component 2/11/11

Audit Red Flags!  New level 4 and 5 visits = or  Physical Exam – requires 30 physical exam bullets including a lymph exam of at least one body area  Medical Decision Making  Level 4 – prescription, aspiration/injection or surgery  Level 5 – surgery with risk, emergent, fracture with dislocation, neurologic loss, discogram, myelogram, arthrogram = risk to life or limb!  Established level 5 visits = 99215

KEYS to Success and Safety  Be an educated coder (just like you are an educated physician and surgeon)  Work backwards – if you wrote a prescription/inject/schedule surgery document the remainder of the requirements and charge an E4.  Attend AANA/AOSSM Coding ICL!!! 2/11/1

Questions? Thanks