Medical billing and coding: Achieving success

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Medical billing and codingAchieving success
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Objectives

• Identify BWCs payment methodologies.
• Discuss new strategies to facilitate appropriate
  bill payment.
• Show the importance of understanding and
  providing medical documentation specific to BWC.

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Provider Fee Schedule Current methodologies

• Hospital inpatient services Diagnosis Related
  Groups (DRG) reimbursement system
• Level I HCPCS codes Resource Based Relative
  Value Scale (RBRVS) methodology
• Level II HCPCS codes Historical and third-party
  payer data/recommendations from professional
  associations.
• Ambulatory surgical centers Nine payment groups
  identified by Medicare  
• Outpatient hospital services Cost to charge
  ratio (CCR)   16

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Provider Fee Schedule Payment rate comparisons

• Professional services
• In general, BWCs rates are similar to workers
  compensation payments in other states.
• Comparable to Pennsylvania higher than
  California, Florida and West Virginia
• BWCs payments are substantially higher than
  Medicare.
• 22 CPT codes accounted for 50 of total payments
  to physicians
• Payments for these services averaged 133 of
  Medicare and ranged from 116211 of Medicare

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Provider Fee Schedule Payment rate comparisons

• Ambulatory surgery centers
• BWCs rates are similar to workers compensation
  payments in other states.
• Comparable to Florida (some higher, some lower)
• Lower than Pennsylvania
• Higher than West Virginia
• BWC pays 133 of Medicare on average.

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Provider Fee Schedule Payment rate comparisons

• Inpatient hospital
• BWCs DRG rates are similar to workers
  compensation payments in other states.
• Slightly lower than California (115 vs. 120)
• Comparable to Pennsylvania
• Higher than West Virginia
• BWC pays at 115 of Medicare.

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Provider Fee Schedule Payment rate comparisons

• Outpatient hospital
• BWCs rates are similar to workers compensation
  payments in other states.
• Comparable to Pennsylvania (some higher, some
  lower)
• Higher than Florida and West Virginia
• BWCs payments are difficult to compare to
  Medicare rates since the payment methodologies
  differ.

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Provider Fee Schedule 2008

• HCPCS Level I and II
• Fee schedules (professional and supplies)
• ASCs
• Payment groups
• Inpatient Hospital
• DRGs
• Outpatient Hospital
• Cost to charge ratio 16

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Provider Fee Schedule Coding requirements

• Effective Oct 1, 2007, BWC will recognize the
  2008 version of the International Classification
  of Diseases (ICD-9-CM).
• Effective for dates of service beginning Jan. 1,
  2008, BWC will recognize 2008 HCPCS Level I,
  Level II, and Level III codes.

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National Provider ID (NPI)

• BWC will continue to accept bills containing only
  BWC legacy (or current) numbers, as well as bills
  with both the legacy number and NPI.
• Verify information with BWCs provider relations
  department.
• Phone [phone], option 3 then 0
• Fax [phone]
• MailBWC Provider Enrollment
  P.O. Box
  182031
  
  Columbus, OH 43218-2031

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NPI

• BWC will process both CMS-1500 forms and UB-04
  and UB-92
• Electronic version of CMS-1500 has increased
  number of diagnosis code accepted to eight.
• You can find line-by-line instructions in chapter
  4 of BWCs Billing and Reimbursement Manual
  online.

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Clinical editing

• Bills validated to meet health-care industry
  coding standards
• MCOs required to use nationally recognized
  guidelines
• Consistent with expected results

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15K Medical-Only Claim Program

• 1K Program Claim is medical only with date of
  injury (DOI)
• 5K Program Claim is medical only with DOI
  June 30, 2006, and
• 15K Program Claim is medical only with DOI
  Sept. 10, 2007
• Participating employers will notify providers

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15K Medical-Only Claim Program

• MCO does not manage claim or reimburse for
  services.
• Bill employer directly for services related to
  injuries covered by the program.
• Pay all bills within 30 days of receipt as billed
  or according to prior agreement with medical
  provider.

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Grievance hearing

• Procedure allows a provider, employer or employee
  to grieve a disputed bill payment, including
• Grievances involving a providers objection to
  the denial of payment or reduced payment
• Appeals regarding the recovery of overpayments.
• It does not address BWC fee schedule grievances
  or alternative dispute resolution (ADR) issues.

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Explanation of benefits (EOB) 776

• Payment made for a non-allowed, related condition
  
• Supporting medical documentation needed to
  substantiate determination to override and pay
  the bill

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Appropriate use of EOB 776

• Treatment authorized by MCO based on Miller
  Criteria for condition not specifically allowed
  in the claim, but related to the allowed
  condition.
• Injured worker develops a post-operative
  infection which may resolve within a few weeks.
• Injured worker develops post-operative
  complications, such as deep vein thrombosis or
  pulmonary embolism, which could require
  re-hospitalization
• IW develops complications related to treatment
  for the allowed conditions i.e. adverse reaction
  to the medications

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Appropriate use of EOB 776

• Treatment not requiring prior approval is
  provided and billed with a non-allowed ICD-9.
• Symptoms indicating that further diagnostic
  studies are necessary to determine if a more
  extensive work-related injury (than previously
  believed) has occurred.

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Inappropriate use of EOB 776

• The condition is expressly denied in the injured
  workers claim.
• The MCO note does not document that Miller
  Criteria has been met.

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Inpatient hospitalizations

• BWC reimburses with a version of the Medicare DRG
  system. BWC implemented this process beginning
  Jan. 1,2007.
• Approximately 6,000 inpatient bills per year
• Hospital reimbursement and review staff
• Includes a certified coder

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Inpatient hospitalizations

• Documents necessary for the review process
  include
• History and physical
• ED report (if applicable)
• Operative note (if applicable)
• Discharge summary or progress notes if stay is
  more than 48 hours
• Discharge note if stay is less than 48 hours.

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Inpatient hospitalizations

• BWC recognizes correct coding guidelines for DRG
  reimbursement.
• Regardless of allowed condition, coding should
  reflect medical record documentation of the
  treating physician.

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Medical documentation policy E-learning

• BWC Learning Center External User Quick Tips
• What is the BWC Learning Center?
• It is a Web-based application that can be
  accessed here www.bwclearningcenter.com.

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Medical documentation policy E-learning

• To search for or enroll in a learning event
  using the BWC Learning Center, follow these
  instructions.
• Visit www.bwclearningcenter.com.
• Click First Visit.
• Enter your (or your employers) BWC policy
  number, your first name and last name.
• Enter a login ID and a password of your choice.
• Click Submit.
• Complete a User Profile.

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Medical documentation policy E-learning

• If your name is entered in the system, you will
  be directed to contact BWC.
• E-mail BWCLearningCenter_at_bwc.state.oh.us.com
• Phone 1-800-OHIOBWC, option 2, 2, 2
• To update your user profile, follow these
  instructions.
• From the home page, click User Information
  Center.
• Click Student Records.
• Click Update Profile.
• Edit as needed.
• Click Submit to save changes.

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Medical documentation policy E-learning

• To enroll in a learning event, follow these
  instructions.
• From the home page click on the Learning Center
  building/icon.
• Click on Course Information Enrollment.
• Search by keyword, entering a word(s) that is
  closely related to the desired training event.
• Click Search.

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Medical documentation policy E-learning

• To enroll in a classroom learning event, follow
  these instructions.
• From the returned list, locate the desired course
  and click on the information icon.
• In the lower right section of the screen, locate
  the date/location of your choice.
• Click Enroll.
• If you have given an e-mail address, you will
  receive an e-mail confirming your enrollment.

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Medical documentation policy E-learning

• If you have no e-mail address, you will receive a
  fax or letter.
• Once you are enrolled, you can view your list of
  selected classes (and cancel, if needed) in the
  Personal Learning Center, which is located on the
  left side of the home page.
• To take an online learning event, follow these
  instructions.
• From the returned list, locate the desired online
  course and click on the title.
• Click Take Course.

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Medical documentation policy E-learning

• To access the Personal Learning Center, follow
  these instructions.
• On the left side of the home page, click on
  Personal Learning Center.
• The list will display current learning events
  (classroom session enrollment and online tutorial
  stated).
• Click the Transcript tab.
• Locate the learning event (classroom or online)
  you have completed.
• Click on Certificate.
• A survey will open if required for completion of
  the learning event.
• When certificate displays click the Print icon to
  print it.

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Documentation

• Evaluation Management (EM) services
• EM services are primarily the same as CMS rules
  with changes instituted for BWC purposes.
• Only one EM service per injured worker per day
  will be reimbursed.
• Credit given for additional effort required to
  treat a new injury or revise return-to-work
  restrictions.

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Documentation

• Established patient
• Injury or worsening of the condition that causes
  a repeat office visit requiring a more thorough
  evaluation
• May include an injured worker with a new injury,
  though the injured worker, based on accepted
  terminology, is considered an established patient

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Documentation

• Social history
• This criterion could be met by a thorough
  occupational history.
• Its often necessary for documentation of
  causality and return-to-work restrictions. 

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DocumentationExamination

• Either 95 or 97 EM guidelines exam criteria
• 95 body areas and organ systems elements
• 97 bullet system
• Most favorable to provider

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DocumentationMedical decision making

• Number of diagnoses or management options
• Return-to-work restrictions
• Are essential in the management of injured
  workers
• Are valued as a part of management option
• May increase the complexity of management
  decisions.

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DocumentationMedical decision making

• Amount and/or complexity of data to be reviewed
• BWC administrative forms completed during a visit
  are
• Counted as a data element
• Worth two points, regardless of the number of
  forms.

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DocumentationTime

• Additional time may be considered in the
  selection of the EM code if documentation
  indicates
• Requirement to complete forms or
• Counseling injured worker regarding
  return-to-work restrictions.

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DocumentationTelephone calls (99371-99373 CPT )

• May be reimbursed
• Must be medically necessary
• Must contribute to overall care of the injured
  worker
• Supporting documentation with a brief description
  of the conversation noted

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DocumentationTelephone calls (99371-99373 CPT )

• Codes are not to be used
• In addition to consultation services
  (99241-99255) or team conferences (99361 and
  99362)
• For conversations with an MCO or BWC
• As a replacement for face-to-face interaction
  with the injured worker.

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DocumentationTelephone calls 99371

• Simple or brief most calls will fit into this
  category
• May be used when a provider calls the injured
  worker for
• Consultative reasons
• Medical management
• Coordinating medical management with other
  health-care professionals.

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DocumentationTelephone calls 99371

• Discussion with the employer regarding an injured
  workers status
• Test and/or laboratory results
• Clarify or alter previous instructions
• Integrate new information from other health
  professionals into the medical treatment plan
• Adjust therapy, report on progress of treatment
• Return-to-work status and job restrictions

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DocumentationTelephone calls 99372

• Intermediate telephone call
• To discuss and evaluate new information
• To provide details or to initiate a new plan of
  care
• Covers at least 20 minutes of provider time

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DocumentationTelephone calls 99373

• Complex or lengthy telephone calls
• Lengthy, emergent counseling session with an
  anxious or distraught patient
• Detailed or prolonged discussion with family
  members regarding a seriously ill patient
• Rare occurrence and required at least 30 minutes
  of provider time.

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Medical documentation

• Sept. 15, 2005 Established patient
• CC - Right knee pain
• 40-year-old male presents with right knee pain
  after tripping over an extension cord at work
  (K-Mart stockroom) yesterday. He is now
  experiencing moderate to severe pain. States he
  has no numbness or tingling in the lower leg, but
  says he has a large bruise on the back and side
  of his knee. He is in good health. He has an
  occasional cigarette.
• Patient is alert and oriented. Vital signs are
  normal. Gait is abnormal as he cannot bear weight
  on the right leg. There is a large bruise on the
  posterior and lateral aspects of the knee. There
  appears to be some effusion. He is very tender to
  palpation. Straight leg raise is difficult to
  assess due to pain. Sensation is intact.
• Knee pain with possible ACL tear. Will request
  MRI. Rx-DarvocetN 100mg q 6 hrs prn pain. Will
  call patient to schedule MRI when we receive
  approval.

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Medical documentation

• History
• Chief complaint
• History of present illness
• Brief one to three elements
• Extended four or more
• Review of systems
• Exam
• 95 or 97 guidelines

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Medical documentation

• Medical decision making
• Diagnoses or management options
• Data
• Risk

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Documentation

• Type of history
• Type of exam
• Complexity of medical decision making
• Established patient two/three key components
• CPT code selected

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Documentation

• Osteopathic manipulation therapy (OMT) coding
  guidelines
• Pre- and post-manipulation assessment
• Pre-service work includes
• Reviewing previously gathered clinical data
• Initial or interim history
• Reviewing the problem list.

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Documentation

• OMT coding guidelines
• Pre-service work includes
• Pertinent correspondence or reports
• Prior care
• Review of imaging and other test results, test
  interpretation
• Care planning
• Other important findings.

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Documentation

• An EM service may be billed on the same day as
  OMT.
• It must be significant and separately
  identifiable from OMT.
• CPT modifier 25 is used.
• Examples include
• First visit at which a patient is examined
• Significant change in the injured workers
  condition warrants an additional evaluation
• Change of medications
• Review of additional or new data
• Ordering of laboratory imaging studies, X-rays or
  additional studies.

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Documentation

• Chiropractic manipulative treatment (CMT)
• Pre-manipulation assessment including
• Reviewing previously gathered clinical data
• An initial or interim history
• Reviewing the problem list
• Pertinent correspondence or reports.

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Documentation

• CMT
• Pre-manipulation assessment including
• Prior care
• Review of imaging and other test results, test
  interpretation
• Care planning
• Other important findings.
• Outcome or response to treatment must be
  included.
• The plan for ongoing care is noted.

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Documentation

• CMT
• You may bill EM on the same day as CMT.
• The service must be significant and separately
  identifiable service.
• Modifier 25 is appended to the CPT code.

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Documentation

• CMT
• Examples of EM service billed on same day as CMT
  include
• First visit at which time injured worker is
  examined
• Significant change in injured workers condition.
• Work not included in the CMT includes
• Review of additional or new data
• Ordering of laboratory imaging studies, X-rays or
  additional studies.

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Documentation

• Physical, occupational and massage therapy
  documentation
• Must support CPT code submitted
• Amount of time submitted for time-based physical
  and massage therapy codes
• Inclusion of plan of care
• Flow sheet of modalities and exercises with
  treatment
• Short narrative of function and status with
  summary of response

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DocumentationTime-based guidelines

• Record time in the medical record, including
• Beginning and ending time of the treatment
• Time spent delivering each service.
• Time calculations for multiple procedures
• More than one CPT code billed during calendar
  day, total number of units billed is constrained
  by total treatment time.
• 24 minutes of 97112 and 23 minutes of 97110 were
  furnished, total treatment time 47 minutes.
• Three total units can be billed for treatment
  two units of 97112 and one unit of CPT code
  97110.

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DocumentationUnits reported

• One unit 8 minutes to
• Two units 23 minutes to
• Three units 38 minutes to
• Four units 53 minutes to
• Five units 68 minutes to
• Six units 83 minutes to
• Seven units 98 minutes to
• Eight units 113 minutes to

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Documentation

• Do not bill for services performed less than
  eight minutes.
• Multiple time-based procedures duration of any
  procedure is less than eight minutes and total
  treatment time exceeds eight minutes, figure time
  into total treatment time on that date.
• Time starts when therapist is working directly
  with injured worker.
• Do not count pre- and post-delivery services.
• Intra-service care begins when therapist or
  physician is directly working with the injured
  worker.
• Injured worker should already be in the treatment
  area and prepared to begin treatment.

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Documentation

• Time counted is the time the patient is treated.
• Example
• Gait training requires both therapist and an
  assistant, or even two therapists, to manage in
  the parallel bars.
• Each 15 minutes the patient is being treated can
  count as only one unit of CPT code 97116.
• You should not bill the time an injured worker
  spends not being treated.

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Documentation

• Psychotherapy
• Insight oriented, behavior modifying and/or
  supportive psychotherapy refers to
• Development of insight or affective
  understanding
• Use of behavior modification techniques
• Use of supportive interactions
• Use of cognitive discussion of reality
• Any combination of the above to provide
  therapeutic change.
• Note face-to-face time spent during
  psychotherapy in the medical record.

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Documentation

• Submit procedure code that most closely matches
  face-to-face time spent with injured worker.
• For example CPT codes
• 90804 20 to 30 minutes up to and including 44
  minutes
• 90806 45 to 50 minutes up to and including 74
  minutes
• 90808 75 to 80 minutes up to and including 94
  minutes

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• Questions?