Michelle Lott CPC CPMA Associate Director WSMA Practice

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Michelle Lott, CPC, CPMA Associate Director, WSMA Practice Resource Center

Michelle Lott, CPC, CPMA Associate Director, WSMA Practice Resource Center

Michelle M. Lott, CPC, CPMA Health Insurance Coding Specialist, WSMA Phone: Fax: Email: 206.

Michelle M. Lott, CPC, CPMA Health Insurance Coding Specialist, WSMA Phone: Fax: Email: 206. 441. 9762 800. 552. 0612 206. 441. 5863 mml@wsma. org 2

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts the reimbursement of Medical Practices. • Identify the rules and interpretation for proper usage of Modifiers, including the new -X{EPSU} modifier that supplement Modifier 59. • Identify common reason for claim denials and how to avoid these issues in your practice. • Describe the Medicare’s Value Based Modifier and how it will impact reimbursement. 3

What is medical documentation? Medical documentation gives you a starting point and basis for

What is medical documentation? Medical documentation gives you a starting point and basis for planning patient care. It facilitates the following: • A basis for planning care of your patients • Communication among physicians and other health care professionals • Accurate and timely claim reviews and payments • Justification for claim payments • Legal protection for you and your patients • Protection of your bottom line 4

Documentation Improvement Program Documentation is not about administrative burden, it’s about good patient care!

Documentation Improvement Program Documentation is not about administrative burden, it’s about good patient care! • Clinical Improvements. o Quality and Efficiency Ratings • Compliance with Payer Policies and Guidelines o Ensure prompt and accurate payment for covered services. • Support Reimbursement. o Protection against audits and negative financial penalties. • Improved healthcare delivery. o Value Based Payments 5

Steps to Bulletproof Documentation Ensure Compliance • Create a coding policy and procedures that

Steps to Bulletproof Documentation Ensure Compliance • Create a coding policy and procedures that ensure compliance. Educate Staff • Provide coding education to coders and CDI staff and provide documentation standards to physicians. Coders do not need to know how to document and physicians do not need to know how to code. 6

Steps to Bulletproof Documentation Communicate • Develop communication methods between coders, CDI staff and

Steps to Bulletproof Documentation Communicate • Develop communication methods between coders, CDI staff and physicians. Good communication tools can equal better documentation with more accurate code assignments. Monitor • Audit and monitor physician documentation and coding assignments. 7

Steps to Bulletproof Documentation Review • Put in place a pre-bill review that can

Steps to Bulletproof Documentation Review • Put in place a pre-bill review that can enhance your monitoring and provide an extra measure for those services that have been problematic. Give Feedback • Have an action plan to give praise or take corrective action as needed. Repeat • The education, monitoring and review process should be continuous and cycle through the organization’s review plan. 8

10 Principles of Documentation for Medical Records • 1 - The medical record should

10 Principles of Documentation for Medical Records • 1 - The medical record should be complete, legible, and make sense. • 2 - The documentation of each patient encounter should include: o the date and reason for the encounter; o appropriate history and physical exam in relationship to the patient’s chief complaint; o review of lab, x-ray data and other ancillary services, where appropriate; o assessment and a plan for care (including discharge plan, if appropriate) 9

10 Principles of Documentation for Medical Records • 3 - Past and present diagnoses

10 Principles of Documentation for Medical Records • 3 - Past and present diagnoses should be accessible to the treating and/or consulting physician. • 4 - The reasons for and results of: x-rays, lab tests and other ancillary services should be documented or included in the medical record. • 5 - Relevant health risk factors should be identified • 6 - The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient noncompliance, should be documented. 10

10 Principles of Documentation for Medical Records • 7 - The written plan for

10 Principles of Documentation for Medical Records • 7 - The written plan for care should include, when appropriate: o treatments and medications, specifying frequency and dosage; o any referrals and consultations; o patient/family education; and o specific instructions for follow-up. • 8 - The record should support the intensity of the patient evaluation and/or the treatment, including through processes and the complexity of medical decision-makings it relates to the patient’s chief complaint for the encounter. 11

10 Principles of Documentation for Medical Records • 9 - All entries to the

10 Principles of Documentation for Medical Records • 9 - All entries to the medical record should be dated and authenticated. • 10 - The CPT/ICD-9 -CM codes reported on the CMS-1500 claim form should reflect the documentation in the medical record. 12

Documentation Best Practices With documentation of medical records, particular emphasis must be placed on

Documentation Best Practices With documentation of medical records, particular emphasis must be placed on the five factors that improve the quality and usefulness of charted information. • • • Accuracy Relevance Completeness Timeliness Confidentiality 13

Responsibilities of the Coders • • Must be capable of finding rules governing coding

Responsibilities of the Coders • • Must be capable of finding rules governing coding for each payer and apply them to achieve 100 percent accuracy. In the absence of such rules, be able to research and analyze guidelines from accepted authorities to ensure that the ultimate code decision is reasonable. 14

Are You Always Right? Can You Prove It? Common criteria supporting code decisions can

Are You Always Right? Can You Prove It? Common criteria supporting code decisions can be problematic • • • This is the way I was taught to do it. This is what the carrier told me to do. I’ve been coding this way for years. Everyone does it this way. A consultant/coding mentor told me to do it this way. This was the solution recommended in a trade association publication. 15

Spelling Out Medical Necessity • Medical necessity is largely determined by the payer community,

Spelling Out Medical Necessity • Medical necessity is largely determined by the payer community, usually assigned to them by your contract. o The "General Principle of Medical Record Documentation" from the Federal Documentation Guidelines is: o "If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. " o The provider must document the diagnosis for all procedures that are performed. The provider also must include the diagnosis for each diagnostic test ordered. A common error seen when reviewing medical documentation is that the provider will document a diagnosis and indicate tests ordered, but it is unclear that all the tests ordered are for the diagnosis documented in the assessment. 16

Documentation and Coding that Demonstrates Medical Necessity • Only the documentation found in the

Documentation and Coding that Demonstrates Medical Necessity • Only the documentation found in the patient's medical record should lead coders to the diagnosis(es) relevant to a claim. o Given the many physiological elements or even organ systems involved in most conditions, it is commonly the case that a patient's clinical condition legitimately may be described in a number of different ways, at a number of different levels, and by a number of different (and all reasonable) code selections. 17

Documentation and Coding that Demonstrates Medical Necessity • As long as the documentation reflects

Documentation and Coding that Demonstrates Medical Necessity • As long as the documentation reflects the reality, the coder will not be led to an inappropriate diagnosis. Similarly, a coder's familiarity with NCD or LCD coding requirements promotes correct billing since these coverage determinations are written to assist the coder search for the specific conditions that allow claim reimbursement. 18

Medical Necessity • Understanding and determining medical necessity can be very complex for physicians,

Medical Necessity • Understanding and determining medical necessity can be very complex for physicians, clinicians, coders, and billers. o A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a patient’s family member. A third-party insurance payer may also have another completely different understanding and application of the term. 19

Medical Necessity • Medical necessity documentation from a physician or provider should include the

Medical Necessity • Medical necessity documentation from a physician or provider should include the following: o Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved. o Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. o Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. 20

Medical Necessity • Here are some examples of what some third party payers are

Medical Necessity • Here are some examples of what some third party payers are currently including in their medically necessary verbiage: o Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care. o Treatment is necessary and consistent with generally accepted professional medical standards (i. e. , not experimental or investigational). o Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier. 21

Medical Necessity • Here are some examples of what some third party payers are

Medical Necessity • Here are some examples of what some third party payers are currently including in their medically necessary verbiage: o Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time. o The disbursement of medical care and/or treatment must not be related to the patient’s or the third party payer’s monetary status or benefit. 22

Common E/M Service Documentation Errors History • • Indicate clearly the chief complaint and/or

Common E/M Service Documentation Errors History • • Indicate clearly the chief complaint and/or reason for the visit. o Do not limit the chief complaint to “follow-up” without identifying the problem(s) being followed. Describe the history of the present illness fully and in such a way that the nature of the presenting problem is clear. 23

Common E/M Service Documentation Errors History • • Record Past/Family/Social History (PFSH) appropriately considering

Common E/M Service Documentation Errors History • • Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. o Do not use the term “non-contributory. ” Do not record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates a lower-level service to have been medically appropriate. 24

Common E/M Service Documentation Errors – History • Record the Review of Systems (ROS)

Common E/M Service Documentation Errors – History • Record the Review of Systems (ROS) appropriate for the clinical circumstance of the encounter. o Document an ROS for the system(s) related to the presenting problem. It is required for all levels of systemic review (meaning that it is required for all codes except the least codes in all code families). 25

Common E/M Service Documentation Errors –History • Documentation examples of what counts as a

Common E/M Service Documentation Errors –History • Documentation examples of what counts as a complete ROS: o “Except as above, all other systems are negative. ” o “All other systems reviewed and are negative. ” 26

Common E/M Service Documentation Errors –History • Documentation examples of what does not count

Common E/M Service Documentation Errors –History • Documentation examples of what does not count as a complete ROS: o “ROS – All other negative” o “ROS is non-contributory” o “ROS otherwise unremarkable” 27

Common E/M Service Documentation Errors –History • Per CMS Guidelines: History of Present Illness

Common E/M Service Documentation Errors –History • Per CMS Guidelines: History of Present Illness and Chief Complaint are to be performed by the physician or nonphysician practitioner. o Information gathered by ancillary staff may be considered but must be confirmed and completed by the physician. 28

Common E/M Service Documentation Errors –History • Reviewing information obtained by ancillary staff and

Common E/M Service Documentation Errors –History • Reviewing information obtained by ancillary staff and simply writing a note “Reviewed and accepted” is not acceptable documentation for CMS. o Better to document “Reviewed and Confirmed” or additional detail to the information gathered by ancillary staff. 29

Common E/M Service Documentation Errors – History • Documenting Status of Chronic Conditions o

Common E/M Service Documentation Errors – History • Documenting Status of Chronic Conditions o Documentation should show what actions the physician is taking concerning these conditions and how they affect the chief complaint. o Just because the patient has chronic conditions does not indicate a high level of service. o Example: Some providers use statements such as the following to justify the regular use of high-level procedure codes. "My office represents a Level 3 Trauma Center; " "I'm a specialist"; "Other physicians send their sicker and needier patients to me. " 30

Common E/M Service Documentation Errors – History • • • Documenting status of Chronic

Common E/M Service Documentation Errors – History • • • Documenting status of Chronic Conditions must provide a description of the condition. Inappropriate to list the condition with just a status of “stable”. Example: o HPI: 1) HTN, pressures running in the 130 s, no dizziness; salt intake down. o 2) Dyslipidemia, exercises daily, still taking red rice yeast extract, no muscle aches. o 3) COPD, using inhaler PRN, wheeze reduced w/recent jogging. 31

Common E/M Service Documentation Errors – Exam • • Understand the difference between “Expanded

Common E/M Service Documentation Errors – Exam • • Understand the difference between “Expanded Problem. Focused (EPF)” and “Detailed” examination under 1995/1997 guideline requirements. The difference is not the number of systems examined. Two to seven systems are required for both examinations. o The difference is the detail in which the examined systems are described. 32

Common E/M Service Documentation Errors – Exam • • Always examine the system(s) related

Common E/M Service Documentation Errors – Exam • • Always examine the system(s) related to the presenting problem and do not describe it as “normal” or “negative. ” o Use “normal, ” “negative” and “WNL” notations only to describe unaffected or asymptomatic organ systems. Code the physical examination considering the clinical circumstances of the encounter. 33

Common E/M Service Documentation Errors – Exam • • Avoid documenting exam elements that

Common E/M Service Documentation Errors – Exam • • Avoid documenting exam elements that are unrelated to the presenting problem. Documenting problem lists with no diagnoses are suggested, or else the principal diagnosis is not spelled out clearly. 34

Common E/M Service Documentation Errors – Counseling & Coordination of Care (Time) • The

Common E/M Service Documentation Errors – Counseling & Coordination of Care (Time) • The documentation does not support the requirement that at least 50% of the visit was devoted to counseling and/or coordination of care. o Clinician notes she spent “around 20 minutes, ” or “approximately 35” minutes with the patient. 35

Counseling & Coordination of Care (Time) • • The document doesn’t adequately detail the

Counseling & Coordination of Care (Time) • • The document doesn’t adequately detail the nature of the counseling and/or coordination of care. Counseling with a patient and/or family in one or more of these areas: o Diagnostic test results, impressions and/or recommendations. o Prognosis; Risks and benefits of treatment options o Instructions for treatment or follow-up o Importance of compliance with treatment options o Risk factor reduction o Patient and family education 36

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The copy and

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The copy and paste, or “cloning, ” of the medical records is on the OIG Work Plan for 2012 o Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. o Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary or from visit to visit. 37

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The record must

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The record must be detailed enough to provide comprehensive clinical data to facilitate continuity of care, and it should be concise and pertinent to the current encounter. o Notes using EMR templates can contain pages of useless information, or “fluff. ” 38

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • • For example,

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • • For example, a complete past, family and social history (PFSH) is not required for every patient encounter. o Often, this information is carried over from a previous visit and it has no relevance for the patient’s presenting problem. Many EMR generated notes are too lengthy and contain much more information than needed. 39

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The only time

Common E/M Service Documentation Errors – Cloning or Excessive Documentation • The only time previously populated data should be brought forward is when the information is pertinent to the current encounter. o o For example, it is not medically necessary to document a comprehensive history on the same patient seen two or three weeks prior. Unfortunately, what some EMRs offer is to copy over of all previous history data, or none. 40

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts the reimbursement of Medical Practices. • Identify the rules and interpretation for proper usage of Modifiers, including the new -X{EPSU} modifier that supplement Modifier 59. • Identify common reason for claim denials and how to avoid these issues in your practice. • Describe the Medicare’s Value Based Modifier and how it will impact reimbursement. 41

Revisions to Modifier 59 • • • The -59 modifier is the most widely

Revisions to Modifier 59 • • • The -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI). ” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases. 42

Revisions to Modifier 59 The primary issue associated with the -59 modifier is that

Revisions to Modifier 59 The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify: • Different encounters; • Different anatomic sites; and • Distinct services. 43

Revisions to Modifier 59 The -59 modifier is • Infrequently (and usually correctly) used

Revisions to Modifier 59 The -59 modifier is • Infrequently (and usually correctly) used to identify a separate encounter; • Less commonly (and less correctly) used to define a separate anatomic site; and • More commonly (and frequently incorrectly) used to define a distinct service. 44

Revisions to Modifier 59 CMS released CR 8863 that establishes four new HCPCS modifiers

Revisions to Modifier 59 CMS released CR 8863 that establishes four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier: • • XE Separate encounter XS Separate structure XP Separate practitioner XU Unusual non-overlapping service 45

Revisions to Modifier 59 While CMS will continue to recognize the -59 modifier in

Revisions to Modifier 59 While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. • This will impact and change the NCCI Coding Edits. • These modifiers are valid even before national edits are in place. 46

Revisions to Modifier 59 Examples of the use of the new modifiers; please note

Revisions to Modifier 59 Examples of the use of the new modifiers; please note CMS has not published specific examples. • XE - Separate Encounter: The patient receives an outpatient infusion of antibiotics (CPT code 96365) at 8: 00 AM, leaves the facility and returns at 8: 00 PM for another infusion of the antibiotics. The second line item 96365 would require the -XE modifier. 47

Revisions to Modifier 59 Examples continued: • XS - Separate Structure: A skin lesion

Revisions to Modifier 59 Examples continued: • XS - Separate Structure: A skin lesion of the arm was destroyed via laser surgery and reported with CPT code 17000 (Destruction (e. g. , laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e. g. , actinic keratoses); and another lesion is biopsied on the leg and reported with CPT code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane including simple closure, unless otherwise listed; single lesion). CPT code 11100 would require the modifier - XS. 48

Revisions to Modifier 59 Examples continued: • XP - Separate Practitioner (for physician reporting):

Revisions to Modifier 59 Examples continued: • XP - Separate Practitioner (for physician reporting): A laparoscopic hernia repair (CPT code 49650) was performed in the morning by surgeon A; later in the day the patient developed acute abdominal pain and a laparoscopic appendectomy (CPT code 44970) was performed by surgeon B. The -XP modifier would be applied to CPT code 44970. 49

Revisions to Modifier 59 Examples continued: • XU - Unusual non-overlapping service: Two separate

Revisions to Modifier 59 Examples continued: • XU - Unusual non-overlapping service: Two separate lesions are present that are within the same code set, and are excised separately - i. e. a 4 cm. lipoma is excised on the upper thigh (CPT code 27337 - excision tumor soft tissue thigh/knee subcutaneous greater than 3 cm) and a separate lipoma excised on the lower leg (CPT code 27327 - excision tumor soft tissue thigh/knee subcutaneous less than 3 cm). The -XU modifier would be applied to code 27327. 50

Advanced Care Planning New E/M Section created to report Advanced Care Planning • Services

Advanced Care Planning New E/M Section created to report Advanced Care Planning • Services provide counseling and discussions on advance care directives. • Requires a Face-to-face encounter, but does not require the patient to be present. • Time based • No active medical management Invalid by Medicare as another code is used for the reporting and payment of these services. 51

Advanced Care Planning CPT Code 99497 Advanced care planning including the explanation and discussion

Advanced Care Planning CPT Code 99497 Advanced care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and or surrogate • +99498 each additional 30 minutes (List separately in addition to code for primary procedure) 52

Advanced Care Planning • WSMA Resources o http: //www. wsma. org/washington-end-of-life-consensuscoalition o Polst o

Advanced Care Planning • WSMA Resources o http: //www. wsma. org/washington-end-of-life-consensuscoalition o Polst o Advance Directives o End of Life Coalition 53

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts the reimbursement of Medical Practices. • Identify the rules and interpretation for proper usage of Modifiers, including the new -X{EPSU} modifier that supplement Modifier 59. • Identify common reason for claim denials and how to avoid these issues in your practice. • Describe the Medicare’s Value Based Modifier and how it will impact reimbursement. 54

Are You Always Right? Can You Prove It? Common criteria supporting code decisions can

Are You Always Right? Can You Prove It? Common criteria supporting code decisions can be problematic Faulty assumptions • This is what I learned at a seminar/from an article in a well known coding magazine. • This was the manufacturer’s recommendation on how to code it. • That is what was recommended in a carrier newsletter/carrier 55

The Fundamental Coding Rule • • Coding is a language and the code set

The Fundamental Coding Rule • • Coding is a language and the code set rules require that we all use the same words. Each carrier has its own dialect. The codes can mean different things to different carriers even when the meaning is contrary to the description. 56

Claim Denial Trends On a broader scale, research by the American Medical Association (AMA)

Claim Denial Trends On a broader scale, research by the American Medical Association (AMA) indicates that claim denials dropped by 47% in 2013 after a sharp increase in 2012 among most commercial health insurers. • Overall, the denial rate for commercial health insurers decreased from 3. 48% in 2012 to 1. 82% in 2013. • Among all insurers last year, Medicare had the highest denial rate at 4. 92%, while Cigna had the lowest denial rate at. 54%. 57

Claim Denial Trends Relatively comparable to the AMA’s findings are recent figures from the

Claim Denial Trends Relatively comparable to the AMA’s findings are recent figures from the Medical Group Management Association (MGMA). • The percentage of claims denied on first submission is 3. 8%, according to MGMA’s most recent study, “Cost Survey Report: 2013 Report Based on 2012 Data. ” • According to an estimate by the Center for Medicare and Medicaid Services, claim denial rates could skyrocket by 100% to 200% in the early stages of coding with ICD-10. 58

Claim Denials • • Rejected claims can be a major drain on revenue. According

Claim Denials • • Rejected claims can be a major drain on revenue. According to the Medical Group Management Association (MGMA), most practices spend an average of $25 to $30 each time they resubmit a corrected claim, which can amount to thousands of dollars each year. Practices that never bother to resubmit, however, leave far more money on the table. 59

THE POTENTIAL FINANCIAL IMPACT OF DENIALS* Denied claims per physician per month 44 Rework

THE POTENTIAL FINANCIAL IMPACT OF DENIALS* Denied claims per physician per month 44 Rework cost per claim $25 Rework cost per month $1, 100 Annual rework cost $13, 200 • *This example assumes 370 visits per month, one claim line per claim, and a denial rate of 12 percent. 60

Common Claim Errors – Due to Registration 1. Incorrect and/or incomplete patient identifier information

Common Claim Errors – Due to Registration 1. Incorrect and/or incomplete patient identifier information (e. g. , name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid) • Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state -issued identification (passport, drivers license, etc. ) and insurance card, so that you are sure to have the proper spelling, group numbers, etc. , on hand. 61

Common Claim Errors– Due to Registration 2. Coverage terminated • Solution: Verify insurance benefits

Common Claim Errors– Due to Registration 2. Coverage terminated • Solution: Verify insurance benefits prior to services being rendered. 3. Services non-covered/Require prior authorization or precertification • Solution: You should contact the patient’s insurance and confirm coverage prior to services being rendered. Patient’s will be angry if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure. 62

5 Common Documentation Errors Lack of Notes: • Every conversation the physician has between

5 Common Documentation Errors Lack of Notes: • Every conversation the physician has between themselves and the patient regarding, care, treatment, preventatives and testing should be documented in the chart. Inadequate history taking: • Physicians need to take the necessary steps of interviewing patients about their past medical history, allergies, drug use, family history and names of other doctors that are treating them. 63

5 Common Documentation Errors Fields left blank • If the question was answered, even

5 Common Documentation Errors Fields left blank • If the question was answered, even with a negative or unknown answer this should be made known in the medical record. For instance if the patient has no known drug allergies, instead of just leaving the drug allergies section blank, NKDA should be recorded in the field. Careless Handwriting Medication Problems: • Prescriptions and refills must be adequately documented. 64

Claim Denials • Medicare and many private payers often reject claims for services deemed

Claim Denials • Medicare and many private payers often reject claims for services deemed “not medically necessary. ” o In some cases, the diagnosis does not align with the service provided, or the procedure/service is covered only at certain frequencies. o Either way, the quick fix is to confirm insurance coverage and authorizations before each patient visit. 65

Claim Denials • Misused modifiers are another common culprit. o Modifier 25, for example,

Claim Denials • Misused modifiers are another common culprit. o Modifier 25, for example, applies only to a “significant, separately identifiable evaluation and management service” by the same physician during the same visit. o “Clinicians often depend on the billing staff to know when a modifier is required, but sometimes they don’t have the clinical expertise to differentiate between modifiers. Training is the key to avoiding this predicament. 66

Claim Denials • Claims containing coding errors related to the place of service are

Claim Denials • Claims containing coding errors related to the place of service are also commonly rejected. • Many errors occur when the billing staff is not sure where the service was rendered. Especially in this day and age of changing entities. • Confusion over primary and secondary insurance is also a problem. • Secondary payers will generally deny a claim if it is submitted without a primary explanation of benefit. 67

Claim Denials • • • A duplicate claim was submitted when a practice hasn’t

Claim Denials • • • A duplicate claim was submitted when a practice hasn’t received reimbursement. A patient hasn’t met the deductible for the calendar year. Services are bundled and the provider receives on combined payment. The benefits have been exceeded. Deficient claims information. 68

Steps to Resolve Denials • In short, to maximize reimbursement, medical practices should understand

Steps to Resolve Denials • In short, to maximize reimbursement, medical practices should understand their payer policies, verify insurance information, identify common scenarios for claims issues, and investigate remarks on remit tance advice notices to prevent repeat denials. 69

Steps to Resolve Denials Streamlining front office administrative tasks • • • Scheduling &

Steps to Resolve Denials Streamlining front office administrative tasks • • • Scheduling & appointments Preparing forms Keeping information organized and easily accessible Creating charts Collecting payments Verifying insurance coverage and reimbursements 70

Steps to Resolve Denials Billing • Billing tasks o Each lost or incomplete charge

Steps to Resolve Denials Billing • Billing tasks o Each lost or incomplete charge slip represents significant loss of revenue. Additionally, hours of staff time is spent each day entering charge slips and tracking down missing information. • • Assigning proper diagnosis & billing codes Payor & patient billing Claims management Accounts receivable 71

Critical actions for understanding and preventing claim denials. • • Look to see what

Critical actions for understanding and preventing claim denials. • • Look to see what improper payments were found by various entities: o OIG reports: www. oig. hhs. gov/reports. html o CERT reports o RACs www. cms. hhs. gov/cert Conduct an internal assessment to identify if you are in compliance with Medicare rules. 72

Critical actions for understanding and preventing claim denials. • Monitor activities being conducted by

Critical actions for understanding and preventing claim denials. • Monitor activities being conducted by Recovery Audit Contractor (RAC) audits o RACs required to post information on areas being audited. o Information also includes information on regulations and guidance that support the audits. 73

Critical actions for understanding and preventing claim denials. • Insurer Billing Guides/Provider Manuals o

Critical actions for understanding and preventing claim denials. • Insurer Billing Guides/Provider Manuals o • Access to individual insurers policies can vary and sites can be difficult to search. o o o • The nature of healthcare requires practices to well versed in payer policies and guidelines. Administrative Guidelines Clinical Policies or Guidelines Reimbursement Policies Carrier Newsletters o Provides updates monthly/quarterly 74

Critical actions for understanding and preventing claim denials. • Stay Informed on Payment Policies

Critical actions for understanding and preventing claim denials. • Stay Informed on Payment Policies o Incorporate payment policies affecting code assignment in your coding policies and procedures. o Maintain a copy of the provider bulletin that addresses this policy with your coding policies and procedures. 75

Applying Coding Rules: Getting Paid Right! Critical actions for understanding and preventing claim denials.

Applying Coding Rules: Getting Paid Right! Critical actions for understanding and preventing claim denials. Choose your tools • • • You can tackle denials with high-tech tools or with old-fashioned paper. A practice that uses paper charts can still use a computerized claims scrubber that checks claims before they're submitted. Practices can also use other software solutions: o Coding Selection Software o Online Claim Check Tools 76

Critical actions for understanding and preventing claim denials. Appeal denials thoroughly support and document

Critical actions for understanding and preventing claim denials. Appeal denials thoroughly support and document your argument. • You can obtain additional supportive documentation through the various sources such as: o AMA CPT Manual, CPT Assistant o National medical specialty societies, state medical associations. o Centers for Medicare and Medicaid Services (CMS) to substantiate the physician’s service. 77

Critical actions for understanding and preventing claim denials. • Prepare an appeal letter that

Critical actions for understanding and preventing claim denials. • Prepare an appeal letter that includes all the relevant data to identify the claim. o Review Coding Guidance, Coding Polices, and a Payer policies. o Forward all relevant documentation to all involved parties, including the patient. 78

Critical actions for understanding and preventing claim denials. • Tell the insurer what you

Critical actions for understanding and preventing claim denials. • Tell the insurer what you want first o Reconsideration, review or re-evaluation, comparison with other claims. o The dollar amount you are requesting and why you believe that amount to be fair. • Explain your justification with documentation o Provide supporting documentation. o Request Insurer to provide justification of denial. 79

Tips for Keeping Consistent • Ensure Consistent Training o Provide all coders with the

Tips for Keeping Consistent • Ensure Consistent Training o Provide all coders with the same education and training; roll out information on updates to all staff at the same time • Audit to Identify Inconsistencies o Conduct regular audits or reviews; address inconsistencies and errors with focused training • Check Educational Sources o Monitor the sources staff use to obtain coding advice; ensure all coders use credible, official sources for guidance 80

Tips for Keeping Consistent • Keep Cheat Sheets Current o Ensure staff's personal "cheat

Tips for Keeping Consistent • Keep Cheat Sheets Current o Ensure staff's personal "cheat sheets" contain up-to-date and accurate information; consider creating authorized sheets for the facility's coding manual • Gather Staff for Discussions o Use periodic staff meetings to discuss common questions and relay consistent advice the entire team can use • Promote Open Communication, Centralize Answers 81

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts

Agenda • Describe the nuisances of EM Coding and Documentation and how this impacts the reimbursement of Medical Practices. • Identify the rules and interpretation for proper usage of Modifiers, including the new -X{EPSU} modifier that supplement Modifier 59. • Identify common reason for claim denials and how to avoid these issues in your practice. • Describe the Medicare’s Value Based Modifier and how it will impact reimbursement. 82

Value-Based Modifier (VBM) VBM assesses both quality of care furnished and the cost of

Value-Based Modifier (VBM) VBM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. • Begin phase-in of VBM in 2015, phase-in complete by 2017. • Implementation of the VBM is based on participation in Physician Quality Reporting System. 83

Value-Based Modifier (VBM) • Beginning January 1, 2016, the Value Modifier will be applied

Value-Based Modifier (VBM) • Beginning January 1, 2016, the Value Modifier will be applied to physician payments under the Medicare PFS for physicians in TINs with 10 or more eligible professionals, provided that at least one physician submitted a Medicare claim during 2014 under the TIN. CY 2014 is the performance period for the Value Modifier that will be applied in 2016. 84

Value-Based Modifier (VBM) • Beginning January 1, 2017, the Value Modifier will be applied

Value-Based Modifier (VBM) • Beginning January 1, 2017, the Value Modifier will be applied to physician payments under the Medicare PFS for physician solo practitioners and physicians in groups with two or more eligible professionals, as identified by their TIN. CY 2015 is the performance period for the Value Modifier that will be applied in 2017. • CMS provides specific policies through rulemaking regarding application of the Value Modifier to TINs participating in Medicare Shared Savings Program ACOs, Pioneer ACOs, the CPC initiative, and other similar initiatives. 85

CY 2017 VM Payment Adjustment Amounts for Groups with 2 -9 EPs and Solo

CY 2017 VM Payment Adjustment Amounts for Groups with 2 -9 EPs and Solo Practitioners Cost/Quality Low quality Average quality High quality Low cost +0. 0% +1. 0 x* +2. 0 x* Average cost +0. 0% +1. 0 x* High cost +0. 0% * Groups and solo practitioners are eligible for an additional +1. 0 x if reporting measures and average beneficiary risk scores are in the top 25% of all beneficiary risk scores, where ‘x’ represents the upward payment adjustment factor 86

CY 2017 VM Payment Adjustment Amounts for Groups with 10+ EPs Cost/Quality Low quality

CY 2017 VM Payment Adjustment Amounts for Groups with 10+ EPs Cost/Quality Low quality Average quality High quality Low cost +0. 0% +2. 0 x* +4. 0 x* Average cost -2. 0% +0. 0% +2. 0 x* High cost -4. 0% -2. 0% +0. 0% Groups are eligible for an additional +1. 0 x if reporting measures and average beneficiary risk scores are in the top 25% of all beneficiary risk scores, where ‘x’ represents the upward payment adjustment factor. 87

Value-Based Payment Modifier Quality Measures • CMS calculates the quality composite score based on

Value-Based Payment Modifier Quality Measures • CMS calculates the quality composite score based on a TIN’s performance on six equally-weighted quality domains: o o o 1) Clinical Process/Effectiveness 2) Patient and Family Engagement 3) Population/Public Health 4) Patient Safety 5) Care Coordination 6) Efficient Use of Healthcare Resources 88

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are subject to the VBPM in 2015. • 319 of these groups will receive an automatic -1% penalty because they did not register to report for PQRS as a group via registry or web interface or elect the administrative claims group reporting option under PQRS in 2013. 89

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are subject to the VBPM in 2015. • In addition, out of the remaining 691 groups that did satisfactorily participate in PQRS or report as a group via the PQRS administrative claims reporting option: • 127 groups elected to have CMS calculate the VBPM using the quality-tiering methodology that will be mandatory in 2017. 90

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are

2015 Value-Based Payment Modifier results The VBPM results indicate that 1, 010 groups are subject to the VBPM in 2015. • Of these 127 groups: o 14 received an upward adjustment to their 2015 payments o 11 received a penalty of -0. 5% or -1. 0% to their 2015 payments o 102 received no adjustments to their 2015 payments (21 of which did not have enough cost or quality data from 2013 for CMS to calculate the VBPM). 91

Quality-Tiering The quality-tiering analysis under the VBPM provides an upward, neutral or downward payment

Quality-Tiering The quality-tiering analysis under the VBPM provides an upward, neutral or downward payment adjustment based on the group’s performance on quality and cost measures as compared with national benchmark performance data in these areas. • For the 2017 VBPM, which is based on 2015 performance, quality-tiering is mandatory in 2017 for all physicians. 92

Quality-Tiering • In 2017, groups with 2 -9 EPs and solo practitioners will be

Quality-Tiering • In 2017, groups with 2 -9 EPs and solo practitioners will be held harmless from any downward payment adjustments while groups with 10+ EPs may see up to a -4% payment adjustment. • Upward adjustments, or incentives earned under qualitytiering, will be established by CMS after the performance period has ended. • Incentive payments will be based on the aggregate amount of downward payment adjustments determined under budget neutrality requirements. 93

CMS Goals • • “Our goal is to have 85% of all Medicare fee-for-service

CMS Goals • • “Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. ” “Our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. ” 94

Medicare Physician Feedback and Value Modifier Program “Supports the transformation of Medicare from a

Medicare Physician Feedback and Value Modifier Program “Supports the transformation of Medicare from a passive payer to an active purchaser of higher quality, more efficient health care. ” • Four interrelated parts: o o PQRS Physician Compare QRUR Value Modifier • Remains in place through 2018 95

Physician Quality Reporting System NPI fails to report PQRS in this year NPI will

Physician Quality Reporting System NPI fails to report PQRS in this year NPI will be penalized in this year • • 2013 -2015 (-1. 5%) 2014 -2016 (-2. 0%) 2015 -2017 (-2. 0%) 2016 -2018 (-2. 0%) 96

Quality and Resource Use Reports (QRUR) • • • Through its Physician Feedback Program,

Quality and Resource Use Reports (QRUR) • • • Through its Physician Feedback Program, the Centers for Medicare & Medicaid Services (CMS) distributes Quality Resource and Use Reports (QRURs) to physicians to provide detailed information about their performance on the quality and cost of care delivered to Medicare fee-for-service patients. CMS sends QRURs to solo physicians and groups based on their Tax Identification Numbers (TIN). Each report includes performance information on PQRS quality measures, claims-based outcome measures, and claims-based cost measures and compares performance to similar peer groups. 97

Quality and Resource Use Reports (QRUR) • • CMS uses the quality and cost

Quality and Resource Use Reports (QRUR) • • CMS uses the quality and cost data to calculate payment bonuses and penalties under the Value-based Payment Modifier Program—and eventually will determine financial bonuses and penalties under the new Merit-Based Incentive Payment System (see more below). Use your QRUR to your advantage to inform care delivery to receive bonus payments and avoid penalties. 98

Quality and Resource Use Reports (QRUR) • Assistance with understanding QRUR reports! o Qualis

Quality and Resource Use Reports (QRUR) • Assistance with understanding QRUR reports! o Qualis Health is one of the nation's leading population healthcare consulting organizations, partnering with our clients to improve care for millions of Americans every day. We work with public and private sector clients to advance the quality, efficiency and value of healthcare. o They offer assistance to practices with Interpretation and Quality Improvement. o http: //www. qualishealth. org/ 99

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 • This bipartisan legislation permanently repeals the sustainable growth rate (SGR) formula and stabilizes Medicare payments for physician services with positive updates from July 1, 2015, through the end of 2019, and again in 2026 and beyond. 100

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 The SGR formula is permanently repealed, avoiding the 21. 2 percent payment cut. • Positive updates for 4 1/2 years. • The law includes annual updates of: 0 percent for January 2015 through June 2015; • 0. 5 percent for July 2015 through 2019; and 0 percent for 2020 through 2025. 101

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 114 -10 • For 2026 and beyond, the update will be 0. 75 percent for eligible alternative payment model (APM) participants; and 0. 25 percent for all others. • The Medicare Payment Advisory Commission (Med. PAC) must report to Congress by July 1, 2019, with “recommendations for any future payment updates for professional services under such program to ensure adequate access to care is maintained by Medicare beneficiaries. ” 102

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 114 -10 • It replaces Medicare’s multiple quality reporting programs with a new single Merit-based Incentive Payment System (MIPS) program that makes it easier for physicians to earn rewards for providing high-quality, high-value health care, and it supports and rewards physicians for participating in new payment and delivery models. 103

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 The “Merit-based Incentive Payment System” (MIPS) quality program: • Beginning in 2019, MACRA provides bonuses for physicians who score well in the MIPS • A new pay-for-performance program under the current Medicare fee-for-service payment system. 104

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 • Current penalties under the Physician Quality Reporting System (PQRS), Electronic Health Records/Meaningful Use (MU), and the value-based payment modifier (VBM) will end at the close of 2018. • In 2019, the MIPS program will become the only Medicare quality reporting program. 105

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 • Performance and “composite scores” under the MIPS will be based upon four categories: o o quality (PQRS/30 percent); resource use (VBM/30 percent); MU (25 percent); and clinical practice improvement activities (15 percent). 106

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), H. R. 2, Pub. Law 11410 • These will build and improve upon the current quality measures and concepts in PQRS, MU, and VBM. • Physicians are specifically encouraged to report quality measures through certified EHR technology or qualified clinical data registries. • Participation in a qualified clinical data registry will also qualify as a clinical practice improvement activity. 107

State Resources • • Washington State Department of Health http: //www. doh. wa. gov/Home.

State Resources • • Washington State Department of Health http: //www. doh. wa. gov/Home. aspx Office of the Insurance Commissioner http: //www. insurance. wa. gov/ 108

Federal Resources • • CMS Online Manual System - http: //www. cms. gov/Regulations-and. Guidance/Manuals/index.

Federal Resources • • CMS Online Manual System - http: //www. cms. gov/Regulations-and. Guidance/Manuals/index. html CMS Conditions of Participation (Co. Ps) and Conditions for Coverage (Cf. Cs) - http: //www. cms. gov/Regulationsand-Guidance/Legislation/CFCs. And. Co. Ps/index. html 109

Other Resources Coding Networks Medical Association/Specialty Society • Advocacy on your behalf • Track

Other Resources Coding Networks Medical Association/Specialty Society • Advocacy on your behalf • Track common ongoing issues • Work with all parties to resolve issues AMA Resources • CPT Guidelines • CPT Network • CPT Assistant 110

Resources • • • Emergency Medical Treatment & Labor Act (EMTALA) - http: //www.

Resources • • • Emergency Medical Treatment & Labor Act (EMTALA) - http: //www. cms. gov/Regulations-and. Guidance/Legislation/EMTALA/index. html National Correct Coding Initiative Edits - http: //www. cms. gov/Medicare/Coding/National. Correct. Cod. Ini t. Ed/index. html Medicare Learning Network (MLN) http: //www. cms. gov/Outreach-and-Education/Medicare. Learning-Network-MLN/MLNGen. Info/index. html 111

Resources • • U. S. Department of Health & Human Services - http: //www.

Resources • • U. S. Department of Health & Human Services - http: //www. hhs. gov/ Office of Inspector General - http: //oig. hhs. gov/ 112

Thank You For more information, contact Michelle Lott, CPC, CPMA MML@wsma. org 206. 441.

Thank You For more information, contact Michelle Lott, CPC, CPMA MML@wsma. org 206. 441. 9762