CPT Coding, Cash, and Compliance Thomas Weida, M.D. Professor Penn State Milton S. Hershey Medical Center Odds and Ends

12/4/2014 © 2014, Thomas J. Weida, M.D. -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Best to have two different diagnoses E&M -25 and procedure code Ideally document two independent notes or at least easily identify the E&M component and the procedure component CPT 2000, pg

Example: Laceration Established patient comes in with a 2 cm laceration of his right upper arm which occurred when she was pushed by a crowd of shopper on Black Friday. You evaluate cause, tetanus status, and size of the wound. You determine sutures are needed and proceed to perform this service. How to code? 12/4/2014 © 2014, Thomas J. Weida, M.D.

How to code example laceration Laceration repair trunk <2.5 cm E&M: ICD-10: –S41.111A Laceration without foreign body of right upper arm, initial encounter –W52.XXXA Crushed, pushed or stepped on by crowd or human stampede, initial encounter 12/4/2014 © 2014, Thomas J. Weida, M.D.

12/4/2014 © 2014, Thomas J. Weida, M.D. Oh, by the way If, during a preventive medical service ( , ) the patient presents with a separately identifiable problem significant enough to require additional work, can bill a E/M code with modifier –25. Use two separate diagnosis: – ICD-9: V70.0 or V20.2 for preventive visit and a medical diagnosis. –ICD-10: Z00.01 (General adult medical exam with abnormal findings) and a medical diagnosis Do two separate notes or easily differentiate the two services in the one note.

12/4/2014 © 2014, Thomas J. Weida, M.D. Examples of Medical Visits with Preventive Exam Which Warrant Separate Billing Strains requiring additional workup Infections requiring prescription Conditions referred to a specialist Chronic conditions with changed treatment

12/4/2014 © 2014, Thomas J. Weida, M.D. Examples of Medical Visits with Preventive Exam Which DO NOT Warrant Separate Billing Rash not requiring prescription or workup Bump that is normal Chronic condition that has not changed and no change to treatment plan is warranted

12/4/2014 © 2014, Thomas J. Weida, M.D. Forms Code Establish a charge you will use Need to develop policy and process on billing for form completion. Who charges? What are the exceptions? When is fee collected? Patient Education.

12/4/2014 © 2014, Thomas J. Weida, M.D. Billing for Tobacco Cessation Counseling – ICD9 Codes Tobacco Use Disorder V15.82 History of Tobacco Use No longer need to provide other clinically relevant diagnosis code, such as cough Document time spent counseling regarding tobacco cessation ICD-10 has different codes

Prolonged Physician Service with Direct Patient Contact, Outpatient Does not have to be continuous time Face to face time (New for 2015: telehealth qualifies) Use with E&M code which has ave. time listed < 30 min: NO Code min: X min: X 1 and >105 min: X 1 and X 2 or more for each additional 30 min (must be greater than 15 min additional for each use of 99357) 12/4/2014 © 2014, Thomas J. Weida, M.D.

12/4/2014 © 2014, Thomas J. Weida, M.D. Waiver of Liability Advance Beneficiary Notice Advanced notification to the patient that his/her insurance may not cover a particular service. The Waiver serves as an agreement that the patient will be financially responsible for those services, i.e. cosmetic surgery. A blanket waiver is not acceptable. It is signed only for those services which may be determined to be “not medically necessary.” Example: Removal of skin tags

Anticoagulation Management Medicare does not pay –Initial 90 days of therapy, minimum of 8 INR’s –Outpatient on warfarin with physician review, interpretation, patient instructions, dosage adjustments if needed, and ordering additional tests –Each subsequent 90 days of therapy, minimum of 3 INR’s. 12/4/2014 © 2014, Thomas J. Weida, M.D.

Cerumen Removal: RUC Recommended. CMS not accepted. Changed from bilateral to unilateral For bilateral use for second ear Used for impacted cerumen Only used when instrumentation used – curette, forceps, and/or suction For irrigation – included in the E/M code Nonfacility: RVU 1.40, Payment $50.15 Facility: RVU 0.95, Payment $ /4/2014 © 2014, Thomas J. Weida, M.D.

Inter-professional Telephone/Internet Consultation Codes: Time based codes Used when advice sought by another specialist who is treating the patient Provider-to-provider telephone or internet consult for Dx and/or management of problem not requiring a face-to-face visit New or established patients. Cannot be used if accepting transfer of care prior to the consult 12/4/2014 © 2014, Thomas J. Weida, M.D.

verbal and written report99446 : Inter-professional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting clinician; 5-10 minutes 99447: minutes 99448: minutes 99449: 31 minutes or more 12/4/2014 © 2014, Thomas J. Weida, M.D.

New Telehealth Medicare Payment Eligible G0438, G0439 – Medicare Annual Wellness Visit 99354, – Prolonged E&M Service 90846, – Family Psychotherapy – Psychoanalysis Requires interactive telecommunications with a minimum of audio and video equipement permitting two-way real time interactive communication. 12/4/2014 © 2014, Thomas J. Weida, M.D.

CMS Proposed 10 day global period to transition to 0-day global period by day global period to transition to a 0- day global period by /4/2014 © 2014, Thomas J. Weida, M.D.

SGR 21.2% cut to physician payments effecitve April 1 unless Congress fixes the SGR formula now or kicks the can down the road again by April 1. 12/4/2014 © 2014, Thomas J. Weida, M.D.

12/4/2014 © 2014, Thomas J. Weida, M.D.

12/4/2014 © 2014, Thomas J. Weida, M.D or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress) Abrupt neuro status change (TIA, Sx, weakness, sensory loss) 40 min

12/4/2014 © 2014, Thomas J. Weida, M.D chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain diagnosis Acute illness with systemic symptoms Acute complicated injury 25 min