1. Basic Billing and Coding Susan Moore Faculty Indiana University Adapted from The Coker Group Alpharetta, GA

2. A Nurse Practitioner Faces Risks at Each Patient Encounter  Clinical Risk Treatment plan errors Patient outcomes Perceived bad treatment by patient  Compliance Risk False claims HIPAA compliance issues  Financial Risk Authorizations and certifications Private payer regulations Patient/payer mix Can’t pay, won’t pay, late payments

3. OIG Reports that for First Half of 2007 Collected $2.9 billion in investigations Excluded 1,278 providers Prosecuted 209 criminal actions Won 123 civil actions OIG Semi-annual report www.oig.hhs.gov/publications/docs/semiannual/2007www.oig.hhs.gov/publications/docs/semiannual/2007

4. Resources  CPT – Identifies the services which are provided during an encounter (Annual)  ICD-9 – Identifies why a service was provided during an encounter (Medical Necessity) (Semi-annual)

5. Regulations All health care professional regulation is:  Performed at the state level  Enacted by state legislature  Administered by state regulatory agency  U.S. Congress is not involved in health care profession regulation

6. Regulation States will specify:  Education requirements  Certification/Licensure  DEA registration  Prescribing restrictions  Physician/NP supervisory ratio  Scope of practice

7. Medicare Guidelines  NPs who treat Medicare patients Must have National Provider Identifier (NPI) Can choose to bill “incident to” or under own number When billing under MD PIN = 100% When billing under own PIN= 85%

8. When NP Bills Under Physician PIN (“Incident To”)  Use carrier guidelines for “incident to” New patient – see MD for care plan establishment Follow up – see NP for “incident to” New problem – see MD or bill under NP number  Office/clinic when physician on site Within ‘shouting’ distance Physician on site does not have to be who initiated care plan but does have to be part of the practice  May be independent contractor  May be W-2 leased employee  Practice must cover expense of NP salary

9. “Incident To” Is Never Appropriate In A Hospital Setting BUT “Shared” visits are! Both MD & NP see patient face to face Both document their findings on the chart Combine documentation & bill under MD PIN Consults can NOT be shared anywhere

10. Shared Services Apply “shared visit” rule (patient seen by several providers) to services provided in the place-of-service: 21 (hospital inpatient) 22 (hospital outpatient) 23 (emergency room) 24 (ambulatory surgical center)

11. Third Party Payers Guidelines For Payments Differ Among Carriers  Do they recognize NPs  Amount of supervision of NP  Who can render that supervision  Where the service needs to be rendered  The scope of services the NP is permitted to render  They can be different from state regulations  Generally differ among carriers

12. Coding Overview  CPT Codes (with modifiers) 99254 - Inpatient Consult What you did  ICD9 Codes (to 4 th or 5 th digit) 786.50 - Chest Pain Why you did it Coding = using numbers to tell a story

13. Coding causing no payment  Wrong code used  Incorrect use of CPT code  Inappropriate unbundling of CPT  Required modifier omitted  Diagnosis does not support service  2 providers bill for same service  Insufficient documentation

14. Who is Responsible for Coding?  Appointment schedulers  Receptionist/patient intake specialist  Clinical staff/ancillary staff  Nurse practitioners/physician assistants  Physicians  Billers/coders  Managers/administrators

15. CPT – Coding and sites The CPT code assigned Depends on nature of presenting problem Work physician performed (History, Exam, Medical Decision-making) Documentation in chart Physician/NP/PA services provided in Office Inpatient Nursing home Outpatient Home

16. Undercoding E/M codes can impact revenues by this example of under coding  For example, Average reimbursement 99212 = $36.20 Average reimbursement 99213 = $50.32 Average reimbursement 99214 = $78.91 Coding 1000 visits a year as 99212 when supported 99213 = $ 14,120 Lost revenue

17. Provider Utilization Comparison http://www.cms.hhs.gov/statistics/feeforservice/default.asp

18. Implications  If your practice is much different than the national practice norms for your specialty then your practice is a red flag.  Therefore, know the national averages for what is happening with your type of practice

19. Evaluation & Management of Coding Charting tells the reviewer History CC, HPI, ROS, Family, Social Exam System(s) & Detail Decision Making Complexity & Risk

20. E&M Charting – How Staff Can Help but NP is KEY History HPI – must be recorded by provider CC,ROS, F&SH – Can be recorded by staff and/or patient with new patient form and reviewed by provider Exam Staff can perform & record three of seven vital signs Decision Making Documentation of lab, x-ray, etc. Medication list update Problem list update

21. Coding Level of History + Level of Examination + Complexity of Medical Decision Making = Correct Code !

22. Nature of presenting problem  How long does it take you to discern how involved a visit is going to be?  How often do you review the past medical, family, and social history?  When do you do a complete 8 organ system examination?  How much time do you spend with each patient?

23. CPT Clinical Examples in the CPT Book  The clinical examples, when used with E/M descriptors, provide a comprehensive and powerful tool for reporting services provided to patients  Submitted by specialty associations to the AMA for the CPT book  Must be used with documentation guidelines

24. Clinical Examples - 99212  10 year old female, established patient, who has been swimming in a lake, now with 1 day history of L ear pain with purulent drainage  Established patient follow up of clearing patch of localized contact dermatitis  65 year old, established patient, with eruptions on both arms from poison oak exposure Straight forward, brief, focused

25. Clinical Examples - 99213  60 year old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check  62 year old female, established patient, for follow-up for stable cirrhosis of the liver Expanded, low complexity, 2 to 4 systems evaluated

26. Clinical Examples - 99214  32 year old female, established patient, with new onset right lower quadrant pain  68 year old established patient, for routine review and follow up of non-insulin dependent diabetes, obesity, hypertension and congestive heart failure. Complains of vision difficulties and admits dietary noncompliance. Patient is counseled concerning diet and current medications adjusted.  77 year old male, established patient, with hypertension, presenting with 3 month history of episodic substernal chest pain on exertion

27. Clinical Examples - 99215  Evaluation of recent syncopal attacks in a 70 year old woman, established patient  30 year old male, established patient with 3 month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly.  70 year old female, established patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation and short term memory loss

28. Important is the medical necessity  “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.  The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported

29. Try Your Knowledge  33 year old female, established patient, follow up for recently started treatment for hemorrhoid complaints, resolving  50 year old, established patient with diabetes, diet controlled. Now complains of frequency of urination and weight loss, blood sugar 320 and negative ketones on dipstick  65 year old, established patient, with stable diabetes and stable coronary artery disease, for monitoring

30. Decision Making from Coker Group 2007

31. Risk Table

32. History from Coker Group, 2007

33. Examination summary from Coker Group, 2007

34. New or Established Patient  “New Patient” is a patient who has not received any professional services from the physician within the previous 3 years. Physicians in Group Practice  In same specialty – bill and be paid as though they were a single physician  In different specialties – bill and be paid without regard to membership in the same group

35. Consultations  Performed at the Request of a physician or other appropriate source (must be documented)*  Report of findings provided to requesting physician  Recommendations for treatment are made * guidelines further clarified in CMS Transmittal 788, January 2006

36. Documenting Counseling Visits  Total face-to-face time choose level of service by total face time  Show counseling took > 50% of time  List medically appropriate topic(s) “I spent 35 minutes total time with this patient, over half involved in discussing importance of compliance with diet instructions.”

37. Medically Appropriate Counseling  Diagnostic results  Prognosis  Risk & benefits of management option  Instructions for mgmt &/or follow-up  Importance of compliance  Risk factor reduction  Patient & family education

38. New ICD-9 Codes October 1, 2007  144 revised or new codes  Published May 3, 2007 Federal Register  No grace period!  Failure to use may result in rejected claims after October 1, 2007

39. Have You Seen Services Denied Because:  “The information in your case does not support the need for this treatment”  “Medicare does not pay for this service for this illness or condition”  “Medicare does not pay for this many services in this time period”  “Services for same illness by more than one doctor are denied” Then you have been denied payment because of lack of medical necessity.

40. Diagnosis Coding Must…  Support and be “mapped” to the service rendered  Be carried to the 4th or 5th digit if applicable  Be reported to the highest degree of specificity  For Medicare payment, must be supported by Local Medical Review Policy

41. CMS Guidelines and Medical Necessity “The rationale for ordering diagnostic and other ancillary services should be easily inferred if not documented.” “The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be reflected by the documentation in the medical record.”

42. Most Over-Reported ICD-9-CM Diagnoses  285.9 Anemia, unspecified  401.9 Unspecified hypertension  429.2 Arteriosclerotic cardiovascular disease  786.50 Chest pain  724.9 Unspecified disorder of the back  784.0 Headache  786.05 Shortness of breath  789.00 Abdominal pain

43. Example:  Patient comes into office complaining of a burning pain in his stomach. He describes as moderately severe and improves when he takes antacid. Nurse Practitioner suspects an ulcer and refers the patient to a gastroenterologist for endoscopy. Today’s diagnosis is:

44. Code to highest degree of specificity  Abdominal pain 789.00unspecified site 789.01RUQ 789.02LUQ 789.03RLQ 789.04LLQ 789.05periumbilic 789.06epigastric 789.07generalized 789.09other unspecified

45. Concurrent Care  May be denied “services not separately payable”  Documentation must reflect that each provider managed separate problem For example:484.3 pneumonia 033.3 pertussis

46. Compliance Issues with Diagnosis Coding  Coding a “rule out” or “suspected” condition as a confirmed diagnosis  Using a slightly higher level of diagnostic code in order to support the care given  Coding diagnoses that are no longer applicable  Not supplying diagnosis or reason for service when ordering ancillary tests  Not obtaining a signed waiver from Medicare patient before rendering a service that may not be covered for the diagnosis given

47. Summary  Follow “incident to” and “shared visit” guidelines when billing for Nurse Practitioner services  Select the E/M code based on the level of service performed and medical necessity  Document the work according to CMS Documentation Guidelines  Use consultation and new patient codes appropriately  Add modifiers to indicate something “out of the ordinary” took place  Code only documented diagnoses