New Provider and Reappointment Training Neonatology Documentation and Coding March 2019

Course Objectives Review basic principles of coding and documentation of neonatology services Review resident/fellow supervision and documentation requirements for Medicare, Medicaid, and TRICARE Review data replication and scribe policies

Principles of Coding and Documentation Appropriate billing requires three components: Doing only what is medically necessary Documenting what is done Billing what is documented Understanding and applying coding and documentation conventions allows for compliant billing, potential for increased revenue, and generally improved quality of the medical record documentation.

Compliance is Essential to Proper Reimbursement Appropriate documentation and billing practices make for good patient care and maximized compensation. Federal Oversight: Recovery Audit Contractors (RACS)—Medicare, Medicaid and commercial insurers pay third party contractors to recoup inappropriately documented or billed services Office of Inspector General (OIG), Health & Human Services—works with the Department of Justice to investigate suspected abuse or fraudulent claims Routine error rate testing and auditing programs

Newborn Care Services

Critical Care Services Critical care is the direct delivery by a physician of medical care for a critically ill patient. A critical illness acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single or multi-system failure. Critical care for neonates and pediatric patients up to 2 years of age are billed once per day. After 2 years of age, critical care codes (99291) and (99292) are used to capture critical care. These are time-based codes and require that the time spent providing critical care by the attending physician be documented in the medical record.

Neonatal and Pediatric Critical Care Neonatal Critical Care Pediatric Critical Care 99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger 99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger 99471 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age 99472 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age CPT © 2019

Neonatal and Pediatric Critical Care The following services are included in neonatal critical care and may not be separately reported: Administration of blood/blood components (36430, 36440) Administration of intravenous fluids (96360-96361) Administration of surfactant (94610) Bladder aspiration, suprapubic (51100) Bladder catheterization (51701, 51702) Car seat evaluation (94780-94781) Catheterization umbilical artery (36660) Catheterization umbilical vein (36510) Central venous catheter, centrally inserted (36555) Endotracheal intubation (31500) Lumbar puncture (62270) Oral or nasogastric tube placement (43752) Pulmonary function testing, performed at the bedside (94375) Pulse or ear oximetry (94760-94762) Vascular access, arteries (36140, 36620) Vascular access, venous (36400-36406, 36420, 36600) Ventilatory management (94002-94004, 94660) CPT © 2019

Documenting Critical Care The following are key phrases which help substantiate critical care services: Impairs one or more vital organ system(s) High probability of deterioration High complexity decision making Assess, manipulate, and support vital system function(s) Treat organ system failure Prevent further deterioration CPT © 2019

Critical Care Time for codes 99291 and 99292 when a resident physician is involved A combination of the Teaching Physician’s (TPs) documentation and the Resident's documentation may support the critical care service. The TP must be present the entire time in order to bill. The medical record documentation of the TP must provide the following information:  Time the TP spent providing critical care,  The patient was critically ill during the time the TP saw the patient,  What made the patient critically ill; and  Nature of the treatment and management provided by the TP. The medical review criteria are the same for the TP as well as for all physicians. Acceptable Attestation: “Patient is in critical condition with ______. I spent ___ minutes providing critical care services of ______. I reviewed the Resident's documentation and I agree with the Resident's assessment and plan of care.”

Pediatric Critical Care Patient Transport 99466 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport 99467 Each additional 30 minutes (List separately in addition to code for primary service) Face-to-face care begins when the physician assumes primary responsibility of the pediatric patient at the referring facility, and ends when the receiving facility accepts responsibility for the pediatric patient’s care. Only the time the physician spends in direct face-to-face contact with the patient during the transport should be reported. Procedure(s) or service(s) performed by other members of the transporting team may not be reported by the supervising physician. These codes should only be reported once per date of service.

Pediatric Critical Care Patient Transport The following services are included in pediatric critical care transport: Blood gases Chest x-rays (71010, 71015, 71020) Data stored in computers (e.g. ECGs, blood pressures, hematologic data) (99090) Gastric intubation (43752-43753) Interpretation of cardiac output measurements (93562) Pulse oximetry (94760-94762) Routine monitoring: Heart rate Respiratory rate Temporary transcutaneous pacing (92953) Vascular access procedures (36000, 36400, 36405-36406, 36415, 36591, 36600) Ventilatory management (94002-94003, 94660, 94662) CPT © 2019

Supervision of Pediatric Critical Care Patient Transport 99485 Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes 99486 Each additional 30 minutes (List separately in addition to code for primary procedure) Only the communication time spent by the supervising physician with the specialty transport team members during an interfacility transport should be reported. These codes should only be reported once per date of service. CPT © 2019

Initial and Continuing Intensive Care Services Used to report services for children who do not meet the critical care criteria but require attentive observation, regular intercessions, and other intensive care treatment. 99477 Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services. 99478 99479 99480 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams) CPT © 2019

Hospital Discharge Services Admitted and Discharged on the Same Date Discharged on a Date Subsequent to the Admission Date 99463 Initial hospital evaluation and management of normal newborn infant admitted and discharged on the same date 99238 Hospital discharge day management; 30 minutes or less 99239 Hospital discharge day management; more than 30 minutes

Delivery/Birthing Room Attendance 99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn 99465 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output Procedures that are performed as a necessary part of the resuscitation (e.g. intubation, vascular lines) should be reported separately. Note: These codes may be reported in conjunction with initial normal newborn care, initial neonatal critical care, or initial intensive neonatal care. CPT © 2019

Standby Services 99360 Standby service, requiring prolonged attendance, each 30 minutes (e.g. standby for cesarean/high risk delivery) The clinician on standby is not permitted to provide care or services to other patients during the standby period. This code should not be used to report time spent proctoring another individual nor should it be used if the standby period ends with the standby clinician performing a procedure that is subject to the surgical package. Standby service of less than 30 minutes total duration on a given date is not separately reportable. Subsequent periods of standby beyond the first 30 minutes may be reported only if a full 30 minutes of standby was provided for each unit of service reported. CPT © 2019

Medical Team Conferences 99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more All participants on the medical team must document their own individual participation in the team conference, in addition to their contributed information and follow-up treatment recommendations. The team conference commences upon review of the individual patient case and concludes once the review has come to a conclusion. The clinician must report all time for which he or she was present. CPT © 2019

Neonatology Consultations A consultation is an E/M service: provided when the opinion and/or advice of one physician is requested by another physician or appropriate source, to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s entire care for a specific condition or problem.

Consultations can be viewed as a three-part cycle (1) a request is made (2) an evaluation is performed and (3) an opinion is rendered and sent to the requesting physician. Request Render Report

Documenting Consultations Documentation of a consultation request must be clearly stated in the note: WRONG: “Patient was referred by Dr. Jones for management of bronchopulmonary dysplasia.” RIGHT: “Patient is seen in consultation at the request of Dr. Jones for evaluation of bronchopulmonary dysplasia.”

Time-Based Billing When counseling and/or coordination of care dominates greater than 50% of the encounter with the patient and/or family, time can be considered the controlling factor for the level of service rather than the history, examination, and medical decision making components. The documentation should describe the counseling and/or activities to coordinate care. Example: “I spent a total of 25 minutes with the patient, of which greater than 50% of which was spent counseling the patient regarding…” In the outpatient setting, the total time is based on the total face-to-face time the provider has with the patient. In the inpatient setting, the total time is based on the total face-to-face time the provider has with the patient as well as the unit/floor time that the provider spends in direct coordination or supervision of care for the patient. Each E/M CPT code has a designated level of time associated with that code. This designated time is used to bill the E/M service when billing based on time.

Teaching Physician Guidelines

North Carolina Medicaid Teaching Physician Requirements Medicaid requires that the TP be "immediately available" to the resident and patient and use "direct supervision" for procedures. Direct supervision does not necessarily mean that the TP must be present in the room when the service is performed but the attending must be in the office suite. The degree of supervision is the responsibility of the TP and is based on the skill, level of training, and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician. Acceptable Attestation for NC Medicaid: “I discussed the patient with the Resident and agree with the assessment and plan as documented.”

TRICARE Teaching Physician Requirements The TP must demonstrate and render sufficient personal and identifiable medical services to the patient to exercise full, personal control over the management of the case. The TRICARE Manual states the TP must: Review the patient’s history and the record of examinations and tests in the institution, and make frequent reviews of the patient’s progress; Personally examine the patient; Confirm or revise the diagnosis and determine the course of treatment to be followed; and Either perform the physician’s services required by the patient or supervise the treatment so as to assure that appropriate services are provided by physicians in training and that the care meets proper quality level; and Be present and ready to perform any service performed by an attending physician in a nonteaching setting when a major surgical procedure or a complex or dangerous medical procedure is performed; and Be personally responsible for the patient’s care, at least throughout the period of hospitalization.

TRICARE Teaching Physician Requirements The responsibilities of a supervisory attending physician are demonstrated by such actions as: Reviewing the patient’s history and physical examination; Personally examining the patient within a reasonable period after admission; and Confirming or revising the diagnosis; Assuring that any supervision needed by the physicians in training was furnished; and Making frequent reviews of the patient’s progress. Simply reviewing a patient’s progress note and not being available when a resident physician in training renders care is not billable to TRICARE. The TP must document his/her presence as also required by Medicare. Acceptable Attestation for TRICARE: “I have seen and evaluated the patient and reviewed the patient’s history, examination and progress. I agree with the assessment, diagnosis and plan of the Resident as documented.

Medical Students CMS defines Student as an individual who participates in an accredited educational program (e.g., a medical school) that is not an approved Graduate Medical Education (GME) program. A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student. Per CMS Policy: Any contribution and participation of a medical student to the performance of a billable service (outside the collection of the system review and history) must be performed in the physical presence of a TP or a Resident. The Teaching Physician or Resident must verify in the medical record all student documentation or findings. The Teaching Physician must personally perform (or re-perform) the physical exam and medical decision making, but may verify any student documentation, rather than re-documenting this work. Note: If a medical student is serving as a scribe, then all requirements for a scribe must be met. See UNC Health Care System Policy SYS014. See UNC Health Care System Policy SYS022 for additional information regarding Medical Student documentation.

Shared Visits with an APP

Documentation Requirements for Shared Visits The following APPs are eligible to bill for shared visits within their scope of practice: Nurse Practitioners; Physician Assistants; Certified Nurse Specialists; and Certified Nurse Midwives APPs must be from the same group practice as the physician. Both the physician and the APP must each personally perform a substantive portion (at least ONE of the three key components: History, Examination, or Medical Decision Making) of an Evaluation and Management (E/M) visit face-to- face with the same patient on the same date of service. It is NOT a shared visit if the physician participates in the service but does not perform and document the face-to-face encounter. It must be medically necessary for both the physician and the APP to see the patient on the same day.

Documentation Requirements for Shared Visits Providers may utilize the .att statement (SmartPhrase) in Epic notating: “It was medically necessary for me to see the patient because ***. My visit included ***.” The medical record should link the APP and the physician notes. A physician co-signature alone or statement, such as, “Agree with the above” is not sufficient

Place of Service Guidelines for Shared Visits Shared visits apply to the following settings: Hospital inpatient Hospital outpatient Emergency Department Shared visits cannot be billed in a physician-based clinic (POS 11) or while providing critical care. When a split/shared visit between an APP and a physician occurs in the office or clinic setting (not hospital-based), the service may be considered to be performed “incident-to”, if the incident-to requirements are met.

Documentation Integrity in Electronic Health Records

Data Replication in Electronic Documentation Altering notes improperly may undermine the integrity of the electronic health record (EHR) and jeopardize reimbursement and patient safety. Medicare does allow documentation changes within limits, including amendments, corrections, addenda, and delayed entries if they are clearly identified and there is no tampering with original content. The billing provider is responsible for the entire content of the documentation including its accuracy and any copied information. Clinical documentation must demonstrate clearly distinct variation between notes. The HPI, ROS, exam, and impression and plan must demonstrate documentation relevant to EACH clinical encounter and be reviewed and edited appropriately. When possible, the use of copying and pasting of laboratory, pathology or radiology results in its entirety should be minimized in order to reduce “note bloat”. Summarizing findings and medical judgment is encouraged. See Policy SYS 011 Copying and Pasting and Data Replication in Electronic Documentation.

Software Features and Capabilities Templates Auto-populating tools and drop down menus may multiply the effect of an incorrect piece of data and may also contribute to the inappropriate up coding of an encounter. Cloning Cloning occurs when an entry in the EHR is worded the exact same way or is very similar to previous entries. When entries are copied and pasted without being edited, medical necessity is not established because the documentation isn’t specific to the current patient encounter. Patient care could be compromised if old treatment plans are copied and pasted.

What are auditors looking for? Inaccurate or outdated information Redundant information, which makes it difficult to identify the current information Inability to identify the author or intent of documentation Inability to identify when the documentation was first created Propagation of false documentation Internally inconsistent progress notes Unnecessarily lengthy progress notes

“Make Me the Author” Function in Epic Allows a provider to substitute their signature for that of another person who entered notes in the EHR. This function does not replace the attestation requirement for a Teaching Physician working with a Resident physician as it does not support the documentation by the Teaching Physician of their face-to-face involvement with the patient during the patient encounter.

Tips to Avoid Re-entering Documentation For physical exams performed that were identical in scope and findings, make a statement in the current note. “Same exam performed as on 11/15/18 with same findings as below.” You may refer to material reviewed in EPIC instead of entering specific detail into the note. “Medication list and medical history reviewed.” “Patient intake form dated November 15, 2018 reviewed; all systems other than those in HPI are negative.”

Use of Scribes Scribes MAY NOT: Provide any clinical care to patients Interject their own observations, impressions or recommendations of care for care into the EMR Scribe Documentation: If the encounter note was written by a scribe, the scribe must sign the note and indicate that they were acting as a scribe.   For example: “Entered by xx, (title), acting as scribe for Dr. Z. Signature (of scribe) Date (xx/xx/xxxx) Time (xx:xx)”   Provider Documentation: The provider should include a statement that they reviewed the documentation, and attest to the accuracy of the note. The provider may add to the note if additional information is needed. The provider then co-signs the note. For example: “The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me. Signature (of provider) Date (xx/xx/xxx) Time (xx:xx)” See Policy ADMIN 0268/SYS 014 Documentation of Care Health Related Data by Scribes.

Contact Us EMAIL AND WEBSITE ProComplianceUNCHC@unchealth.unc.edu http://www.med.unc.edu/compliance http://intranet.unchealthcare.org/intranet/hospitaldepartments/auditcomplianceprivacy/procompliance DIRECTOR Robin Davis Shuping, RN, MHA, CPC | HCS Director, Professional Compliance – UNC Health Care Hedrick Building, Suite G050 211 Friday Center Drive Chapel Hill, NC 27517 Ph (984) 974-1017 | Fax (984) 974-1064 Robin.Shuping@unchealth.unc.edu ASSOCIATE DIRECTOR Laura Bushong, MSJ, CHC, CPC | Associate Director Professional Compliance – UNC Health Care Hedrick Building, Suite G063 211 Friday Center Drive  Ph (984)974-1107 | Fax (984)-974-1064 Laura.Bushong@unchealth.unc.edu