Codes and Payors: 2009 Pediatric Update

Presented by Lynn A Brown, CPC September 18, 2009

ABOUT THE SPEAKER

Lynn Abernathy Brown, CPC

physician office setting.

has over twenty years of experience in medical record coding and reimbursement in a Lynn is employed by Children’s Health System as the Director of Physician Coding and Reimbursement. She is proficient in ICD 9-CM and CPT coding principles specializing in pediatric physician reimbursement issues in the State of Alabama. She is a member of AAPC, MGMA-AL, and 2009 Chair of AL Chapter-AAP Practice Management Association, serves on the AL Medicaid/MASA Coding Workgroup and the AL-AAP Pediatric Council.

DISCLAIMER

  The material in this handout is prepared by the presenter and are statements of fact or opinion based on information from various insurance providers, internet website and other sources available in the medical profession. The statements in no way guarantee payment from any insurance provider and do not imply an opinion or guarantee by Children’s Health System. I have no financial relationships or interests with proprietary entities producing health care goods or services related to the content of this CME activity. My content will not include discussion/reference of any commercial products or services. I do not intend to discuss an unapproved/investigative use of commercial products/devices.

Needs and Objectives

    Update physicians/staff regarding payor changes in Alabama related to CPT and ICD-9-CM coding; Familiarize physicians/staff with major payor medical policies and resource information related to appropriate coding; Be familiar with appropriate use of CPT modifiers; Understand medical record documentation requirements which support CPT and ICD-9-CM coding from payor/auditor’s perspective.

Blue Cross-Blue Shield of Alabama

BCBS-AL CHANGES

 BCBS rules changed 01/21/2009 – Allow modifier 25, 59 – – Allow Preventive and Sick for Pediatrics only Allow Procedures and E/M Codes on same DOS  One copay for Preventive and Sick visit on same day  PMD Fee Schedule changes 12/01/09

PREVENTIVE AND SICK

 Audit Target - Sick Levels (99214/99215) Documentation must support level  Increased Modifier 25 use on auditing radar  Most Sick Visits with Preventive Visit will be at least one level lower than if they had Sick only

Documentation for Well and Sick

 Separate Documentation Required PREVENTIVE CARE VISIT • Comprehensive History • Comprehensive Exam (including documented sick body area/organ system

SICK VISIT – Mod 25

CC HPI MDM

E/M VISIT and 17250

 BCBS – AL

automatically

pays for Preventive Care with Modifier 25 and 17250 (Silver Nitrate Stick) umbilical cauterization  BC does

not

automatically pay Sick visit and 17250 (Silver Nitrate Stick) umbilical cauterization (must appeal)

BCBS NEWBORN FOLLOW-UP

Mgmt of Hyperbilirubinemia in Newborns

• BCBS-AL allows V Codes for Newborn 1 st • Other payors may not allow same V code visit CPT codes: 99201-99205 and 99211-99215 First few days after discharge [see policy guidelines]

V29.3

• Observation and evaluation of newborn for suspected genetic or metabolic condition

V29.8

• Observation and evaluation of newborns and infants for other specified suspected condition not found

Alabama Medicaid

AL MEDICAID UPDATES

 Medicaid no longer requires UA at EPSDT  96372 requires modifier 25 on E/M  NDC number required for generic Rocephin  NDC update to claim now on webportal  Well Baby Care changed to 99461

MCD MODIFIER SCENARIOS

Paid without modifier 25

99391-EP Preventive Care < 1yr 17250 - Cauterization

Paid with modifier 25

99213-25 Established visit Level 3 96372 – Injection Administration

No payment with any EP modifier for Injection Administration

99391-EP Preventive Care < 1yr 96372 – Injection Administration Synagis Administration will not be paid on same day as EP Screening

AL MEDICAID-WELL BABY CARE

 99432 99461 [Medicaid only] effec. 1/1/09 – First 8 weeks of life – – – One time code Does not go against 14 visit limit per year Allows EPSDT screening at 2 – 4 weeks

QTOOL - MEDICAID STATEWIDE EHR

 ePrescribe  BCBS-AL and AL Medicaid claims data  Diagnostic Testing History  Prescription History Contact Kim Davis-Allen for set-up [email protected]

99401-99404 COVERAGE

 BCBS-AL not included on PMD fee schedule  99401 – 99420 Allowable on BCBS-AL PMD fee schedule effective 12/1/09 (may be limited by contract)  Medicaid allows 99401 and 99402

COUNSELING FOR VACCINES

 If counseling goes long due to parental refusal consider using the preventive medicine counseling codes – 99401: preventive medicine counseling and/or risk factor reduction intervention provided to an individual; approx. 15 min – 99402: approx. 30 min – 99403: approx. 45 min – 99404: approx. 60 min.

COUNSELING FOR VACCINES (cont)

 AAP recommends using these codes when the counseling on a vaccine is more involved than normal instead of the vaccine counseling codes.



Document the amount of time spent counseling and a brief description of the counseling

 Example: “Spent 15 min. discussing the vaccines required at 2 months and Mother states is concerned about autism. Discussed pro’s and con’s of vaccines, media information etc.” Bill 99401.

Care Plan Oversight



BCBS-AL

– Per PMD fee schedule, CPO codes not included – As of 12/1/09, 99374-99380 included on PMD fee schedule (may be limited by contract) 

AL Medicaid

– – – Per MCD Fee Schedule,

15-29 minutes

included 99374 – Physician supervising home health 99377 – Physician supervising hospice

Care Plan Oversight (cont.)

 United Healthcare – per Reimbursement Policy available on UHC website – – – – Allows for reimbursement of

30 minutes and up

99340 – Physician supervision of home patient 99375 – Physician supervising of home health 99378 – Physician supervising hospice

CARE PLAN OVERSIGHT

 EXAMPLE: – – Newborns under care of Home Health Agency providing Phototherapy or other care Per CPT, “These codes should not be reported for supervision of patients… unless they require recurrent supervision of therapy.”

CARE PLAN OVERSIGHT FORMAT

     

Documenting Care Plan Oversight Services

• Patient Name:_____________________ • Diagnosis:________________________ Home Health Care Agency:______________ Date Service Started:______________ • Physician:________________________ • At end of service per month, add total time for all days and if greater than 15 minutes, can bill for these services.

Month

Advice service performed communication Daily Minutes TOTAL MINUTES

Date Date Date

NURSE VISIT

 99211 – Established patient level 1  Recognized by payors as nurse only visit, except BCBS-AL (does not change 12/1/09)  BCBS-AL requires physician/provider to be face-to-face with patient

Developmental Testing Codes

   96110 – Developmental Testing, AAP recommends standard tools: ASQ, PEDS, M-CHAT, Denver, etc Payor Specific: Add Modifier 25 to E/M or Mod 59 to 96110 – – BCBS: Pays with and without Mod 25 currently MCD: Not currently required – Commercial payors: check policies V79.3 – Screening for Developmental Handicaps – Recognized by All-Kids and Medicaid for payment

96110 – Developmental Screening

 ALL-KIDS allows 96110, limited to 4 screenings by age 48 months  Medicaid allows any age  BCBS-AL allows code 96110   Diagnosis and contract determine payment Generally can bill responsible party

INJECTION ADMINISTRATION

 96372 – Therapeutic and Diagnostic Injection – Re-numbered code 2009 – Requires Modifier 25 attached to E/M code

MODIFIERS

MODIFIER 24

 Unrelated E/M Service by Same Physician (Group) during Postoperative Period (Global Days)  Patient returns after treatment of fracture within 90 days for sore throat  99213-24 Office Visit with Pharyngitis 462

MODIFIER 25 and 59

 Modifier 25: Shows service or procedure significantly separate from E/M service  Modifier 59: Shows procedure or service distinct or independent “from other

non-E/M

service performed on the same day…” — Resource for all Modifiers:

CPT Appendix A

MODIFIER 90 & 91

 Modifier 90: Attach to lab test when sent to an outside laboratory  Modifier 91: Attach to the second lab test when a repeat test is performed to confirm findings (not for technical error)

NCCI

 National Correct Coding Initiative  Website for NCCI edits – Comprehensive Column 1, Component Column 2 – – Mutually Exclusive One in Modifier column indicates modifier allowed – http://www.cms.hhs.gov/NationalCorrectCodInitEd /NCCIEP/list.asp#TopOfPage

NCCI MODIFIER EXAMPLE

  94640 – Inhalation Treatment 94664-59 – Demonstration and education of nebulizer, MDI, etc.

 NCCI shows 94664 as a component (Column 2) of 94640 (Column 1) therefore modifier 59 is required on the component code.

NCCI and PAYORS

 Some payors follow NCCI completely and some follow NCCI partially.

 United Healthcare has adopted NCCI policy  Medicaid follows NCCI with the exception of EP modified codes  BCBS-AL partially follows

REAL-TIME CLAIMS ESTIMATOR

Preventive Care with Sick and Mod 25

AETNA CLAIM CHECK

Preventive Care with Sick without adding Mod 25

APPEAL



Appeal process simplified with standard letter for common denials

–

Modifier 25

–

Medical necessity



Payors automatically edit first claim but 60% of claims will be paid on appeal historically



Appeal online through payor website

QUESTIONS?

WEBSITE RESOURCES

 Search any payor name and almost all have a website now with claim status/Eligibility & Benefits, Claim Status, some with Real-Time Claims   INSURANCE PAYOR LIST FOR ELECTRONIC # http://direct.medifax.com/payerlist.asp?page=1   BCBS-AL https://www.bcbsal.org/providers/   AL MEDICAID http://www.medicaid.alabama.gov/billing/   UNITED HEALTHCARE https://www.unitedhealthcareonline.com

  VIVA HEALTH INSURANCE http://www.vivahealth.com/

Web Resources

http://practice.aap.org/

AAP Members Only Practice Management Online

Contains:

Updated RBRVS brochure Carrier appeal letters Private Payer Advocacy Monthly Update Vaccine Financing Resources Carrier Take-back information