Visit Charges and Compliant Billing Chapter 6 Visit Charges and Compliant Billing

Compliant Billing Following guidelines for correct coding Code Linkage Necessary Treatments Accurate and show necessity

Correct Coding Initiative (CCI) Control improper coding/improper payments from Medicare Quarterly code edits – system that checks codes Same procedure, same day, same provider Multiple DME from same provider, same day Medicare billing Rules for correct coding are published in the Federal Register published by CMS Example: checking for reporting surgery with both incision and with scope Checking code combinations which dx codes can be used with which procedure codes Disallows reporting of codes that have been removed from code book Doctors have to report more extensive code for procedures that include lesser procedures burn debridment, biopsy sizes

Office of Inspector General OIG work plan Fraud and abuse initiative Check compliance with billing regulations OIG fraud project found 23,000 billings for E/M services with -25 modifier used with 11055, 11056, 11057 (paring or cutting a corn or callus) -25 is significant separately identifiable E/M b y same surgeon same day Government Payers OIG issues regulations for other government entities such as Medicaid and Tricare They issue advisory opinions and audit reports that summarize findings after investigations. 11055 is one lesion 11056 is 2-4 lesions 11057 is 4 or more lesions Modifier

Private Payer Regulations Similar to CCI Regulations found in contracts, handbooks, and bulletins Private payer guidelines may be different from government guidelines. An insurance company may choose to bundle codes not specified in CPT or may not accept modifiers

ERRORS!!!! Linkage and Necessity Truncated or assumption coding Billing for Noncovered services Separate codes (unbundling) Invalid or outdated codes Upcoding or Downcoding The codes used must indicate medical necessity or other documentation needs to be sent. Examples ate on p. 204 Truncated codes: not as specific as possible. Coding 76499 unlisted diagnostic radiographic procedure When documentation indicates it was an MRI 76390 Assumption coding coding for things not documented but you “think” might have happened (not satisfying the condition for the code) i.e. a code that includes interpretation

Thinking It Through Botox injections have been approved by the FDA as a procedure to treat spasms of the flexor muscles in the elbow, wrist and fingers. Should a payer reject a claim for this use of Botox based on lack of medical necessity? May want to get preauthorization or send documentation proving necessity.

Staying Compliant Know global periods and what is included in packaged codes How many postop days are part of the global package? Compare E/M codes with National averages Use of modifiers Know professional courtesy guidelines Stay educated and up to date Global period -- how long does post procedure cover? Minor procedures for Medicare 0-10 days How long is the global period for procedures or operations? Use modifier -79 for procedures not related to the surgery that take place during the global period Comparing E/M helps evaluate codes being used. Prevent upcoding or downcoding Professional courtesies: waiving the charges for other docs or family. Some states prohibit Medicare illegal Discounts for uninsured and self-pay must be documented as to how patients are selected for the discounts. OIG

Is coding being done properly? Audits Formal review External—by private payers Prepayment audits Postpayment audits Internal—by medical office Is coding being done properly? Monitoring the coding and billing cycle Insurance companies or government review selected records Code linkage, signatures, documentation, completeness Prepayment audits: done by insurance company’s computers before adjudicating check documentation of the visit Postpayment: after payments are made checking that bill was accurate, services were performed at level indicated Internal: Conducted by office’s compliance officer once or twice a year to see whether billing and coding is compliant and analyze skill levels of personnel and need for additional training Are changes and revisions of codes being implemented

E/M Audits CMS/AMA Documentation Guidelines for Evaluation and Management Tool used to reduce subjectivity in assigning level of service Clear examples and descriptions to fit in each category When selecting E/M codes you must know the extend and complexity of the examination and decision making The Documentation Guidelines (p.211) help guide you to accurately coding E/M

Selecting an E/M Code History of Present Illness Location Quality of pain Severity Duration Timing Context Modifying Factors Associating signs and symptoms 1-3 = Problem Focus 4-8 = Extended Pp 210 - 212

Physician Fees Usual fees Fee Schedules Usual fees charged to most of the patients most of the time under typical conditions The range of physician fees are published in a database Fees set by Normal ranges for fees in each geographic area, what government pays in that area

Payer Fee Schedule Charge-based Resource-based UCR RVS RBRVS Usual, customary, reasonable Resource-based RVS Relative value scale RBRVS Resource-based relative value scale Charge-based—UCR of other providers with similar skill and experience UCR -- May decide to pay midrange for that geographic area Resource based – compares Medicare uses RVS Difficulty Office overhead Relative risk involved RVS—scale based on level of skill and time needed to provide service Conversion factor used to determine payment p. 215

Fee-based Systems Allowable Charge by Payer Maximum charge Allowed amount Contract adjustments Patient responsibility is based on allowed amounts when going to a PAR provider Coinsurances are based on allowed charges When a patient goes to a PAR for a noncovered service, pt should receive the discounted insurance rate even if insurance doesn’t pay for that procedure Several math examples on pp 219-220 discuss allowed amounts and balance billing and provider adjustments

Consider This Allowed amount for E/M visit is $160 Provider A charges $180 Provider B charges $140 How much will Provider A collect? $160 How much will Provider B collect? $140

Medicare Allowed is $84 Provider’s usual fee is $200 Medicare pays 80% Patient pays 20% How much will Medicare pay? 80% of $84 67.20

Payer pays 100% of allowable charges. Allowable is $2880 Provider A is PAR and charges $3100 Provider B is nonPAR and charges $3000 How much will payer pay to Provider A? $2880 the allowed amount How much will Provider A write off? $3100 - $2880 = $220 How much will payer pay to Provider B? $2880 the allowed amount How much will Provider B write off? No write off The provider will balance bill the patient

Bundled Payments with Healthcare Reform One payment for one episode of care Instead of being paid more for more tests and more procedures, Healthcare Reform suggests paying a dollar amount for the episode of care Bundling care for treatment into one payment

Capitation Setting cap rates Prepaid monthly payment Demographic of patients and number of visits expected Type of practice (Pediatrics, OBGYN, GP) Prepaid monthly payment Agreed upon covered services (office visits, but not surgery) p. 222 has chart of capitation schedule

Collecting TOS Payments Depends on third-party agreement No collection for Medicaid or Workers’ Comp Payment expectations need to be communicated when a patient signs up to be a new patient.