The Ins & Outs of E/M Coding and Documentation

Transcript The Ins & Outs of E/M Coding and Documentation

Indiana Osteopathic Association 116th Annual Convention May 4, 2013

Presented by Joy Newby, LPN, CPC, PCS Newby Consulting, Inc.

5725 Park Plaza Court Indianapolis, IN 46220 Voice: 317.573.3960

Fax: 866-631-9310 E-mail: [email protected]

This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered. Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the manual are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes service descriptions, instructions, and/or guidelines are copyright 2012 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical Association.

For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation. The American Medical Association assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication.

   ◦ ◦ On January 2 nd , President Obama signed the American Taxpayer Relief Act of 2012 Replaced the 26.5 percent decrease with a 0.0 percent update in the conversion factor Dates of service 1/1/2013 – 12/31/2013 ◦ ◦ Fee Schedule will have changes from 2012 Budget neutrality factor required reduction in conversion factor from $34.0376 to $34.0230 Changes in relative value units Fee Schedule is posted on Indiana Medicare website 4

 2% reduction applies to all original Medicare payments ◦ Applies to all payments made by original Medicare (includes injectable drugs and supplies) ◦ Effective with dates of service on and after April 1, 2013 ◦ Without Congressional action, effective for the rest of 2013 ◦ Claim adjustment reason code (CARC) 223 is used to report the sequestration reduction on EOBs CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 5

         Commercial payers Department of Justice (DOJ) Office of Inspector General (OIG) Zone Program Integrity Contractors (ZPIC) Medicare Administrative Contractors (MAC) Comprehensive Error Rate Testing Contractor (CERT) Medicare and Medicaid Recovery Audit Contractors (RAC) Medicaid Integrity Contractors (MIC) Medicaid Payment Contractors 6

 On February 11, 2013, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius released a report showing that for every dollar spent on health care-related fraud and abuse investigations in the last three years, the government recovered $7.90. ◦ This is the highest three-year average return on investment in the 16-year history of the Health Care Fraud and Abuse (HCFAC) Program.

   Morton Plant Mease Health Care Inc. and its affiliated hospitals (Morton Plant) have agreed to pay $10,169,114 to the federal government to resolve allegations that they violated the False Claims Act by submitting false claims for services rendered to Medicare patients ◦ Morton Plant owns and operates, or is affiliated with, Morton Plant Hospital, St. Joseph’s Hospital, Morton Plant North Bay Hospital, St. Anthony’s Hospital, Mease Countryside Hospital and Mease Dunedin Hospital. These hospitals are part of the BayCare Health System in Florida’s Pinellas, Hillsborough and Pasco counties. The settlement announced resolves allegations that, between July 1, 2006 and July 31, 2008, Morton Plant improperly billed for certain interventional cardiac and vascular procedures as inpatient care when those services should have been billed as less costly outpatient care or as observational status

Whistleblower will receive over $1.8 million as her share of the government’s recovery

   Georgia Cancer Specialists, PC agreed to pay $4.1 million to settle claims that it violated the False Claims Act by billing Medicare for evaluation and management services that were not permitted by Medicare rules. ◦ Georgia Cancer Specialists is one of the largest private oncology practices in the country with 27 offices located throughout the Atlanta metro area.

The settlement announced resolves allegations related to the billing for E/M services on the same day as a related procedure (probably chemotherapy) U.S. Attorney’s Office alleged that Georgia Cancer Specialists applied modifier -25 to claims that did not qualify for its use, leading to overpayments by Medicare CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 9

  American Sleep, headquartered in Jacksonville, Fla., owns and operates 19 diagnostic sleep testing centers throughout the United States, including in Alabama, California, Delaware, Florida, Illinois, Indiana, Kansas, Kentucky, Maryland, Missouri, New Jersey, Tennessee, Texas, and Virginia.

The United States contended that American Sleep submitted false claims to Medicare and TRICARE between Jan. 1, 2004, and Dec. 31, 2011 because the diagnostic testing services were performed by technicians who lacked the required credentials or certifications, when it knew this violated the law. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 10

   Between 2002 and the end of September 2012 Medicare, Medicaid, and numerous private insurers “…it would have been impossible for any physician to provide the medical treatment to that number of patients in a single day. “ ◦ November 29, 2007, February 20, 2008, and June 19, 2008 ◦ Provided services to 82, 85, and 92 patients, and the aggregate “typical” time component associated with the codes submitted for payment were 30 hours, 35 hours, and 40 hours, respectively.

 Settlement resolves the government’s allegations that between 2001 and 2006 EMH and NOHC performed unnecessary cardiac procedures on Medicare patients. ◦ Specifically, the United States alleged that EMH and NOHC performed angioplasty and stent placement procedures on patients who had heart disease but whose blood vessels were not sufficiently occluded to require the particular procedures at issue  Whistleblower will receive $660,859 of the United States’ recovery CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 12

  CMS approved limited review, statistical sampling of evaluation and management claims to calculate and project incorrectly paid claims Connelly, Inc. the Region C Recovery Audit Contractor, ◦ RAC Region C includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico, and the US Virgin Islands.

    Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code It is not appropriate to bill a higher level of E/M service when a lower level of service is warranted The volume of documentation should not be used to determine the level of service Services billed should be individualized to the presenting problem(s) on the date in question.

  Providers should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met Beware of templates that overestimate decision-making. Understand the logic of templates and/or computer programs used for E/M service coding. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 15

 Coverage defined by: Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment for only those services considered body member.

medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 16

 ◦ ◦ Identify all the presenting complaint(s) and/or reason(s) for the visit for which physician work occurred. Demonstrate clearly the history, physical and extent of medical decision-making associated with each problem.

Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent and risk to the patient) was affected by comorbidities or chronic problems listed.

 ◦ ◦ Physician Regulatory Issues Team (PRIT) Surgeons routinely provide focused H&Ps to their surgical patients as part of the preoperative services which are bundled into the payment for the surgery. Patients who have significant comorbid conditions may require a preoperative visit with an internist or subspecialist in which case that visit would be covered.  It would be appropriate for the internist to perform a focused H&P and make recommendations concerning the management of the patient’s comorbid conditions during the preoperative period.

    Medical necessity rules apply Not an admission/facility history and physical ◦ Surgeon’s global surgical package includes the problem focused admission/facility H&P Must be requested by the surgeon ◦ Request must state medical problems needing evaluation to determine patient’s risk of perioperative complications and for optimizing perioperative care Report must be issued stating whether patient is cleared for surgery, additional work-up needed recommendation not to proceed with surgery, etc.

  ◦ Preoperative Diagnostic Tests Defined as tests performed to determine a patient’s perioperative risk and optimize perioperative care Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 20

   All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84) Additional appropriate ICD-9 codes for the condition(s) that prompted surgery Additional appropriate ICD-9 codes for conditions that prompted the preoperative medical evaluation (if any), should also be documented on the claim CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 21



2013 Work Plan

The OIG will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 23

 The OIG will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services.

They will also assess Medicare’s ability to monitor services billed as “incident-to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit.

  After it self-disclosed conduct to the OIG, Bartlett Regional Hospital (Bartlett), Arkansas, agreed to pay $1,434,664.50 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Bartlett submitted claims using incorrect physician names and NPI numbers and submitted claims for non-physician provider services that were billed under a physician's name and NPI number. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 25

   The OIG will describe billing characteristics for Part B clinical laboratory tests in 2010. They will also identify questionable billing for Part B clinical laboratory tests in 2010. In 2008, Medicare paid about $7 billion for clinical laboratory services, which represents a 92-percent increase from 1998. Much of the growth in laboratory spending was the result of increased volume of ordered services. Medicare pays only for those laboratory tests that are ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 26

 The OIG will review Medicare contractors’ procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests and determine the appropriateness of Medicare payments for these tests. It is not considered reasonable and necessary to perform a glycated hemoglobin test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 27

 The OIG will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. They will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. ◦ Medicare contractors have noted an increased frequency of medical records with identical documentation across services. ◦ Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 28

  The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 29

 April 3 - St. Luke’s University Health Network has agreed to pay $1,029,791 to resolve allegations that from January 1, 2002, through June 30, 2012, it erroneously submitted claims to the Medicare program for payment that contained evaluation and management services that were not allowable under Medicare.

◦ Medicare does not normally allow additional payments for such services performed by a provider on the same day as a procedure, unless the service is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure.

 In such cases, an attachment to the claim, known as "Modifier 25," may be submitted to allow the additional payment. ◦ In this matter, the government determined that St. Luke’s incorrectly attached Modifier 25 to Medicare claims that led Medicare to pay for evaluation and management services that were not significant and separately identifiable from the underlying procedures for which Medicare also made payments. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 30

 Eligible professionals may earn an incentive payment for electronic prescribing for 2013.

◦ Eligible professionals who receive the electronic health records incentive payment are not entitled to receive an e-Rx incentive.

 The basics of the e-Rx Incentive Program have not changed.

  Eligible professionals may participate one of two ways ◦ as an individual eligible professional ◦ as part of a group practice participating in the group practice reporting option (GPRO) for the e-Rx Incentive Program (e-Rx GPRO)  Now defined as 25 or more eligible professionals  Must also participate in PQRS For 2013, there are three different reporting mechanisms: ◦ Claims-Based ◦ Registry ◦ Electronic Health Records 32

  Eligible professionals who successfully report the e-Rx measure are entitled to the following incentives: ◦ 0.5 percent for 2013 ◦ ◦ Eligible professionals who do not successfully meet the reporting requirements during the first 6 months of the previous year or do not meet one of the exceptions will have their Medicare fee for service payments reduced for the following year.

1.5 percent for 2013 2.0 percent for 2014 33

    Enrolled in Medicare on or after July 1, 2013 Successfully reported at least 25 unique e-Rx events between January 1 and December 31, 2012 Submit at least 10 unique e-Rx events between January 1 and June 30, 2013 Request and receive an hardship exemption CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 34

  Report the following e-Rx numerator G-code, when applicable: ◦ G8553 At least one prescription created during the encounter was generated and transmitted electronically using a qualified e-Rx system. The e-Rx G-code, which supplies the numerator, must be reported: ◦ on the same claim as the denominator billing code ◦ for the same beneficiary ◦ for the same date of service (DOS) ◦ by the same EP (individual NPI) who performed the covered service as the payment codes, usually ICD-9-CM, CPT Category I or HCPCS codes, which supply the denominator CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 35

  If an eligible professional (EP) earns an incentive under the Medicare EHR Incentive Program, he or she cannot receive an incentive payment under the e-Rx Incentive Program in the same program year If an EP earns an incentive under the Medicaid EHR Incentive Program, he or she can receive an incentive payment under the e-Rx Incentive Program in the same program year.

 The Physician Quality Reporting System is a voluntary quality reporting program that provides an incentive payment to practices whose eligible professionals (identified on claims by their individual National Provider Identifier [NPI]) satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-For-Service (FFS) beneficiaries 37

 For 2012 through 2014, eligible professionals may earn an incentive payment of 0.5 percent of their total  Penalties for not successfully reporting PQRS measures begins in 2015 ◦ 1.5% payment adjustment for 2015 ◦ 2.0% payment adjustment for 2016 and after 38

   2 ◦ ◦ Measure options Individual measures Measures group 3 Reporting Options ◦ Claims based ◦ Registry ◦ Electronic Health Record 2 Reporting Periods ◦ 12 months (January 1, 2013 through December 31, 2013) Claims must be submitted no later than February 28, 2014 ◦ 6 months (July 1, 2013 through December 31, 2013) Must be submitted no later than February 28, 2014 (Measures Group registry reporting only) 39

  

Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus

Description: ◦ Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% Reporting Options ◦ Claims-based ◦ Registry-based Instructions: ◦ This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. The performance period for this measure is 12 months. The most recent quality-data code submitted will be used for performance calculation. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

  An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT E/M service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271 CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 41

 3046F: Most recent hemoglobin A1c level > 9.0% OR  3046F-8P: Hemoglobin A1c level was not performed during the performance period (12 months) OR   3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0% OR 3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 42

  To avoid the 2015 PQRS payment adjustment, individual eligible professionals and CMS-selected group practices participating in the PQRS Group Practice Reporting Option (GPRO) will have to satisfactorily report data on quality measures for covered professionals services provided in 2013. Reporting during the 2013 PQRS program year will be used to determine whether a PQRS payment adjustment applies in 2015 . CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 43

 The Affordable Care Act provides for incentive payments equal to 10 percent of a primary care practitioner's allowed charges for primary care services under Part B, furnished on or after January 1, 2011 and before January 1, 2016. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 44

 Primary care practitioners must meet all the following criteria Physicians who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants for whom primary care services accounted for at least 60 percent of the practitioner’s MPFS allowed charges ◦ New and established patient office or other outpatient visits (CPT codes 99201 through 99215) ◦ Nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340) ◦ Patient home visits (CPT codes 99341 through 99350) CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 45

    No other action required to participate and receive incentive payments Incentive payments are based on the Medicare paid amounts for the CPT codes designated as primary care on the previous slide Incentive payments are made quarterly Primary care practitioners also eligible for the 10 percent Health Professional Shortage Area Bonus are also eligible for the Primary Care Incentive Payment = 20% total incentives for primary care services CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 46

    Under the Affordable Care Act (ACA), states must raise the Medicaid fees they pay for primary care services provided by family physicians, internists, pediatricians, and nurse practitioners and physician assistants to the level Medicare pays for those services.

The purpose of this section of the ACA was to increase the availability of primary care providers in anticipation of increased demand beginning in 2014 under Medicaid expansion.

On average, in 2012, the fees paid for Medicaid primary care services were about 58% of those paid by Medicare.

The increase will especially benefit individuals who are eligible for Medicare and Medicaid since primary care providers now will receive the full Medicare amount.

  Transitional Care Management (TCM) ◦ Covered and paid by Medicare ◦ Other insurers should also reimburse, but will depend on contract Complex Chronic Care Coordination Services (CCCC) ◦ Bundled by Medicare ◦ Contact contracted insurers to know if separately billable CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 48

 The transition in care is from: ◦ an inpatient hospital setting (acute care, rehab, LTAC) ◦ partial hospital ◦ observation status in a hospital ◦ skilled nursing facility/nursing facility  To the patient’s community setting: ◦ home ◦ domiciliary ◦ rest home ◦ or assisted living CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 49

 TCM is comprised of one face-to-face visit within the specified time frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction.

◦ When provided, report TCM code for the first face-to-face visit following discharge ◦ These codes are NOT part of the Teaching Physician Primary Care Exception and require the teaching physician to evaluate the patient when the face-to-face visit is provided by a resident CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 50

  Per CPT, TCM are for services to an established patient and whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care.

 The required contact with the patient or caregiver, as appropriate, may be by the physician or qualified health care professional or clinical staff. ◦ Within two business days of discharge is Monday through Friday except holidays without respect to normal to normal practice hours or date of notification of discharge ◦ Contact may be    Direct (face-to-face) Telephonic, or by Electronic means CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 52

 The contact must include capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care. ◦ If two or more separate attempts are made in a timely manner, but are unsuccessful and other transitional care management criteria are met, the service may be reported.

 99495 Transitional Care Management Services with the following required elements: ◦ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge ◦ Medical decision making of at least moderate complexity during the service period ◦ Face-to-face visit within 14 calendar days of discharge CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 54

 99496 Transitional Care Management Services with the following required elements: ◦ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge ◦ Medical decision making of at least high complexity during the service period ◦ Face-to-face visit within 7 calendar days of discharge CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 55

Non-face-to-face services provided by the physician or other qualified health care provider may include:  Obtaining and reviewing the discharge information (e.g., discharge summary, as available, or continuity of care documents);  Reviewing need for or follow-up on pending diagnostic tests and treatments  Interaction with other qualified health care professionals who will assume or re-assume care of the patient’s system-specific problems    Education of patient, family, care guardian, and/or caregiver Establishment or reestablishment of referrals and arranging for needy community resources Assistance in scheduling any required follow-up with community providers and services CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 56

Non-face-to-face services provided by clinical staff, under the direction of the physician or other qualified health care professional, may include:  Communication (with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals) regarding aspects of care;   Communication with home health agencies and other community services utilized by the patient; Patient and/or family/caretaker education to support self management, independent living, and activities of daily living;    Assessment and support for treatment regimen adherence and medication management; Identification of available community and health resources; Facilitating access to care and services needed by the patient and/or family.

  

Only one individual may report these services and

only once per patient within 30 days of discharge.

◦ Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within the 30 days. Will require good coordination with other physicians involved in the patient’s hospitalization The same individual may report hospital or observation discharge services and TCM.

The same individual should not report TCM services provided in the postoperative period.

◦ If another individual provides TCM services within the post operative period of a surgical package, modifier is not required. (Coding tip, not guideline) CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 58

 ◦ ◦ CCCC Patients: Typically have 1 or more chronic continuous or episodic health conditions Commonly require the coordination of a number of specialties and services ◦ May have medical and psychiatric behavioral co morbidities complicating their care ◦ May have social support weaknesses or access to care difficulties CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 59

 Patients requiring CCCC may be identified by: ◦ Algorithms that utilize reported conditions and services (e.g., predictive modeling risk score or repeat admissions or emergency department use) OR - Clinical judgment CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 60



CCCC Services are:

◦ Patient centered management and support services provided by physicians, other qualified health care professionals (QHP) and clinical staff ◦ Provided to an individual residing in a home or in a domiciliary, rest home, or assisted living facility (not in a skilled nursing facility and not a hospice patient) ◦ A care plan directed by a physician or QHP and typically implemented by clinical staff ◦ Services that address the coordination of care by multiple disciplines and community service agencies.

 The reporting individual provides or oversees the management and/or coordination of services, as needed, for: ◦ All medical conditions ◦ Psychosocial needs ◦ Activities of daily living CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 62

   99487 Complex chronic care coordination service; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to face visit per calendar month 99488 CCCC first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month

99489

each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 63

 Payment for minor surgical procedures includes payment for certain E/M services that are necessary prior to a procedure being performed.

◦ It may be necessary to indicate that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.

  Definition ◦ Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service When a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier -25 should be appended to the visit code.

 ◦ An investigation into the billing patterns of a major healthcare facility in Ohio revealed modifier -25 was being appended to outpatient clinic visits when there was no documentation in the medical records to support that a significant, separately identifiable E/M service was performed.

The overpayment dollar amount for this facility was over $500,000.

  ◦ ◦ Modifier -25 is not used to report an E/M service that resulted in a decision to perform surgery. The -57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit is not billed in addition to the procedure.

Carriers should not pay for an evaluation and management service billed with the CPT modifier -57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.

 A patient comes to the office with complaints of right knee pain. The physician takes a history and does an exam. An X-ray of the knee is obtained and the physician writes an order for physical therapy. He determines that the patient would benefit from a cortisone injection to the affected knee. ◦ In this case, a separate and significant E/M service was prompted by the knee pain for which the cortisone injection was given.

  An established patient is seen in the office for debridement of mycotic nails. In the course of examining the feet prior to the procedure, Tinea Pedis is noted. Use of previously prescribed topical cream to treat the Tinea is recommended. In this case the Tinea was noted incidentally in the course of the evaluation of the mycotic nails and did not constitute a significant and separately identifiable E/M service above and beyond the usual pre and post care associated with nail debridement.

  ◦ Modifier 57 AMA Definition Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

◦ Modifier -57 CMS Definition Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service resulted in the decision to perform the procedure. CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 70

 ◦ ◦ ◦ CMS also instructs physicians to append the -25 modifier even though these services are not subject to the global surgical package pricing Smoking Cessation E/M with IM/SubQ injection of therapeutic medication Problem-oriented E/M on the same day as a Medicare preventive visit, e.g., IPPE, AWV CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 71

    If you perform a test, be certain that the order is noted somewhere in the medical record.

Test requisitions must be personally signed by the provider.

Some tests require a written interpretation and report, e.g., ECGs, x-rays. ◦ The claim must include the valid NPI of the ordering/referring physician or extender.

Individual ordering the test in the medical record must be shown as the ordering provider on the claim (Box 17 & 17B of CMS 1500) for the diagnostic test CPT Codes, Descriptions, and Modifiers Copyright 2012 American Medical Association 72

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