Coding and Billing for Internists Services Challenges and

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 G 0402, instead of old G 0344 § 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,

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_ management/payment_coding/medicare/changes 201 0/feeschedule. 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 2009 Payment Replaceme nt Code 2010 Payment 99241 $48. 69 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 Replaceme nt Code 2010 Payment 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 9925199252 § 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 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

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 99212 -99215 • 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 long-term, 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 § Documentation should note amount of time counseling and what was discussed (must be medically necessary) § List counseling time as fraction of total, e. g. “ccc

Opportunity: Home Health Care Plan Certification/Recertification § Bill HCPC G 0180 for certification of the initial home health care plan • § Medicare pays $58 Bill HCPCS G 0179 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: • • § § § 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 • § Patients taking medications complicated by tobacco use Covers 2 attempts to quit per year • § Patients with disease caused or exacerbated by tobacco use; or Pays $25 Append modifier -25 to office visit (or other service) done on same date

Opportunity: Screening Pelvic/Breast Exam § G 0101 - 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 Q 0091—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 G 0101 § 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

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 _management/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 G 8553 on claim form to indicate an eprescribing 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 /eprescribing/medicare_program. htm

ACP Contacts for Questions/Comments § Regulatory and Insurer Affairs Department § • Brett Baker - bbaker@acponline. org • Debra Lansey - dlansey@acponline. org • Tenita Richards - trichards@acponline. org Center for Practice Improvement and Innovation • Margo Williams - mwilliams@acponline. org