Coding and Billing for Internists’ Services Challenges and Opportunities June 2010 Foundation on which Billing and Coding is Based AMA maintains CPT book.
Download ReportTranscript Coding and Billing for Internists’ Services Challenges and Opportunities June 2010 Foundation on which Billing and Coding is Based AMA maintains CPT book.
Slide 1
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 2
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 3
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 4
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 5
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 6
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 7
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 8
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 9
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 10
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 11
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 12
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 13
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 14
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 15
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 16
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 17
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 18
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 19
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 20
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 21
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 22
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 23
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 24
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 25
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 26
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 27
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 28
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 29
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 30
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 31
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 32
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 33
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 34
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 35
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 2
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 3
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 4
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 5
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 6
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 7
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 8
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 9
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 10
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 11
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 12
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 13
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 14
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 15
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 16
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 17
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 18
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 19
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 20
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 21
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 22
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 23
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 24
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 25
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 26
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 27
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 28
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 29
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 30
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 31
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 32
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 33
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 34
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]
Slide 35
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician
service
Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical
inflation
Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the
interest of its members
Focus on What You Control
General coding and billing guidance
•
•
•
•
•
•
Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of
practice
Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use
modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
•
Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change
Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the
CPT definition of critical care
Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still
recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching
physician’s and resident’s documentation
Examples of acceptable documentation:
•
I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
•
See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of
training program
Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical
time”
Not subject to 1995 or 1997 E/M documentation guidelines
List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
Bill HCPC G0180 for certification of the initial home health care
plan
•
Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
•
•
Use if patient has received home health services within past 60 days
Medicare pays $44
Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if
needed
CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
Medicare covers for:
•
•
Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
•
Pays $13
Bill CPT 99407 for >10 minutes of counseling
•
Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services:
•
Obtaining a smear for screening Pap test Q0091—pays $40
•
Acute/chronic “medically necessary” service, e.g., 99213
•
Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
Telephone services
•
99441 - 5-10 min. medical discussion
•
99442 – 11-20 min. medical discussion
•
99443 – 21 -30 min. medical discussion
•
Must be initiated by established patient call to physician
•
Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
•
99444 – on-line service to established patient
•
Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
Receive bonus if correctly report code a minimum of 25 times
in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]