CODING WITH CONFIDENCE Part 2

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CODING WITH CONFIDENCEPart 2

• Improve your coding knowledge to optimize revenue
  and avoid fraud!
• Leslie Sharpe, FNP
• Pittsboro Family Medicine

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Coding Resources

• Current Procedural Terminology Manual (1st 30
  pages or so)
• Centers for Medicare and Medicaid
  (www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp)
  Downloads for Evaluation and Management Services
  Guide, 1995 Guidelines, and 1997 Guidelines.
• Billing Physician Services Provided by Nurse
  Practitioners in Specialists Offices, hospitals,
  nursing facilities, homes, hospice, Buppert,
  2006.
• The Primary Care Providers Guide to Compensation
  and Quality How to get paid and not get sued,
  2nd Ed., Buppert, 2005.

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Down coding

• Why does it happen?
• Lack of understanding of coding rules and
  guidelines
• Fear of being audited
• Undervaluing time with patient, especially when
  there is counseling involved
• When the patient is a child

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Down-Coding

• Coding fee schedule (approximate)
• 99211--40
• 99212--60
• 99213--80
• 99214--115
• 99215--180
• Procedures and physicals--higher rate of pay

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Down-Coding

• If down-code 20 patients a week from 99214 to
  99213, do the math
• 115 - 80 35
• 35 X 20 patients 700
• 700 X 52 weeks (36,400) potential loss of
  profit

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Down-Coding

• If down-code 3 patients a week from 99215 to
  99214
• 180 - 115 70
• 70 X 3 patients 210
• 210 X 52 weeks (10,920) potential loss of
  profit

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Know your billing mechanisms

• Fee-for-service
• Capitation
• Contracts

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Fee-for-service

• There is a payment associated with every
  procedural code or E M code.
• Increased revenue is related to increased
  billing.
• More visits and procedures means more revenue for
  the practice.

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Capitation Reimbursement

• The practice or institution gets a set amount per
  month for services needed by a patient--contracted
  between insurance company and practice.
• Example--insurance company pays practice
  10/month/patient for all primary care services
  needed for enrolled patients between age 18 - 50
  (may be exceptions for certain chronic
  illnesses).
• Negotiated rates--based on profit projections and
  past utilization of services by male/female/age.

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Contracts

• Practices may have contracts to provide care to
  certain groups of patients
• Workmans compensation
• Urine drug screening
• Employment physicals

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Know your payor sources

• Medicare
• Medicaid
• Managed Care Companies (such as Aetna)
• Commercial indemnity insurers (such as BCBS)

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Patient Visits

• How many patients should you see a day?
• New NPs approximately 6 - 8 patients per 4 hour
  block.
• Established NPs 9 - 15 visits per 4 hour block
• The higher the number of visits, the more revenue
  generated
• Need a variety of visits
• Most visits 99213 - 99214 (insurers expect a bell
  curve with most visits 99212 - 99214)
• Physicals
• Procedures--higher charges
• New patients--higher charges than established
  patients

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Generating Revenue

• If capitation, much of follow-up should be done
  by phone, mailings, or with other staff, not by
  visits with providers (since dont get paid for
  each visit) requires efficient management of
  patients
• If fee-for-service, the more visits and
  procedures, the better for the practice

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Generating Revenue

• Proficiency at coding important
• Encounter forms
• Mark E M code
• Match ICD-9 codes to CPT codes
• Circle all appropriate CPT codes (injections, neb
  treatments including admin kit and medication,
  urinalysis, strep test, etc).
• Documentation to match E M code--makes appeals
  process quicker
• Know the difference between consultation and
  referrals (consultations bill higher)

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Generating Revenue

• Control those factors that you can
• Time off
• Patient schedule (sick visits, physicals,
  follow-up visits, procedures)
• Expenses
• No-shows (some practices can charge for this)
• Knowledge of Medicare rules and regulations
  (relating to incident to visits or shared
  visits)

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Incident to Billing

• Incident to a physicians professional service.
• Integral, although incidental, part of the
  physicians personal professional services in the
  course of diagnosis or treatment of an injury or
  illness. (Medicare definition)
• Billed under the physicians medicare number.
• Medicare pays at 100 (for physician) versus 85
  (for nurse practitioner)

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Incident to Billing

• Services must be rendered under a physicians
  direct personal supervision.
• The non-physician provider must be an employee of
  the physician or physician group.
• The physician performs the initial visit and
  determines the course of management.
• The physician does not have to be in the same
  room, but must be in the building and available
  to provide immediate assistance, if needed.

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Incident to Billing

• If the non-physician provider sees the patient
  for a new problem or illness, the visit cannot be
  incident to, because it is not following the
  prescribed course of treatment.
• It is recommended that incident to notes be
  cosigned by the physician.

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Incident to Billing

• Some clinicians use it very effectively.
• Be very careful.
• Get your own medicare number.
• Incident to billing a favorite red flag for
  auditors.

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Incident to billing

• When not to bill incident to
• New patient
• Established patient with new problem
• Physician not physically in office
• Patient always sees the nurse practitioner
• Hospital patient
• Nursing home patient (except in certain
  circumstances)
• For these patients, bill under the NP number

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Consult versus Referral

• Consult the intent of the visit is to give the
  referring provider recommendations in the care of
  the patient. May also include treatment, but
  eventually, the care goes back to the referring
  provider. Consult codes are used.
• Referral made with the intent for the provider
  to whom the patient is referred to manage the
  care. The provider bills E M visits, not
  consultation codes.

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Consultation

• Provided by a provider whose opinion or advice
  regarding evaluation and/or management of a
  specific problem is requested by another provider
  (not patient-initiated).
• The request and need for consultation must be
  documented in the patient record (consult
  letter).
• After the visit, the consulting provider prepares
  a written report of findings and recommendations
  for the referring provider.

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Case Studies

• Refer to handouts