Coding and Compliance

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Coding and Compliance

• Review for Provider Reappointments

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Course Objectives

• The purpose of this course and its follow-up test
  is to provide physicians and other clinicians,
  who are being re-appointed by UNC Hospitals, with
  important information on three issues

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Course Objectives

1. Why coding and compliance is important to you and
   your practice
2. Keys to correctly coding hospital and office
   visits - Evaluation and Management (EM) Services
   
3. Teaching physician (TP) rules. In order to bill
   for services when working with residents and
   fellows, the teaching physician must abide by
   federal and state laws and regulations

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Why coding and complianceis important to you and
your practice
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Reimbursement
Providing good care while billing accurately and
confidently requires

• Doing only what is medically necessary
• Documenting what you do
• Billing what you document

• Understanding and applying coding and compliance
  conventions can improve the level of
  reimbursement for UNC Faculty Physician practices
  as well as the quality of the medical record
  documentation.

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Why Compliance

• Good documentation and billing practices make for
  good patient care
• Office of Inspector General (OIG), Health Human
  Services
• Routine and probe audits by CMS contractors and
  third parties

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Why Compliance

• Residents are paid through the hospital by Part A
  Medicare. Medicare pays a portion of the
  residents salaries based on the proportionate
  share of Medicare at the teaching hospital
• Teaching physicians (TP) are paid by Part B
  Medicare on a fee-for-service basis
• The government, through Medicare, will pay for
  both resident and TP services if both
  participate. If the TP does not participate in a
  given patient service, the TP may not bill.

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Why Compliance

• Two problems have caused a majority of refunds
  and penalties
• The TP billed and he/she may have been present
  and participated in the care, but TP presence was
  not documented
• The documentation in the note did not support the
  level of service billed

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Keys to correctly coding hospital and office
visits - Evaluation and Management (EM) Services

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Choose the Outpatient Category

• Outpatient EM Categories
• Consultation
• New
• Established

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Use of Consultation Codes

• Outpatient consult codes 99241-99245, inpatient
  consult codes 99251-99255
• Use when expert opinion or advice is requested by
  an appropriate source involved in that patients
  care
• Does not include patients referred for
  management of a condition or self-referred
• Use outpatient consultation codes only one time
  per request, subsequent visits are established
  patient visits

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Use of Consultation Codes

• A consulting physician may initiate diagnostic
  and/or therapeutic services at the same visit and
  the initial visit remains a consultation
• Written or verbal request must be documented in
  the rendering physicians note and the
  consultants opinion communicated by written
  report to the requesting physician. The shared
  medical record is sufficient communication for
  providers in the UNC system
• Medicare has not recognized consultation codes
  since 2010, but Epic translates the consultation
  codes to the appropriate EM category and level
  for Medicare.
• Providers retain Relative Value Units (RVUs)
  associated with the consult for productivity
  measures.
• Please continue to bill consultation codes for
  all payers when provided and documented.

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Documenting Consultations
Documentation of a consultation request must be
clearly stated in the note WRONG Mr. Patient
was referred by Dr. Jones for management of GERD
symptoms. RIGHT Mr. Patient is seen in
consultation at the request of Dr. Jones for
evaluation of abdominal pain. Please be sure to
include the referring provider in the in the
referring provider field. This will help in
communicating a letter to the provider that
requested a consult. A letter can be sent to the
requesting provider through the communications
tab in Epic.
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New Patient

• New Patient CPT codes 99201-99205
• Has not received any professional evaluation and
  management (EM) services from the physician or
  another physician of the same specialty who
  belongs to the same group practice within the
  past three years, including inpatient, outpatient
  or emergency room
• A patient would still be considered new if a
  diagnostic procedure was billed without an EM
  visit charge

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Established Patient

• Established Patient CPT codes 99212-99215
• Has received an EM service from the division
  within the past three years including inpatient,
  emergency room or inpatient or outpatient
  consultations

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Visit Components

• Consults and new patient visits must
  include all three of the following components
  established patient visits must include any two
  of the three
• History
• History of present illness
  Documenting History
• Review of systems
  History example
• Past family and social history
• Physical examination 1995
  Physical Exam
• 
  1997 Single Organ Exams
• Medical decision Making
• Diagnosis and management options
  Documenting MDM
• Amount and complexity of data reviewed
• Overall risk
  Risk Table

Click these links for more information
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Visit Levels

• Billing at a higher level than actually provided
  and/or documented is one of the two chief issues
  contributing to CMS fraud allegation settlements
• There is a laminated, pocket-sized physicians
  coding card that may be a valuable guide to
  correct coding. To request a copy of this card
  please call 919-843-8638
• Questions on correct coding and compliance issues
  should be directed to the Compliance Auditors at
  919-843-8638
• Click on this link for documentation requirements
  at various EM levels of service

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Visit levels based on time

• Document the total time of the visit
• Over 50 of an outpatient visit must be spent in
  face-to-face counseling and treatment planning
  and so documented. For Medicare patients, count
  only face to face time between the Teaching
  Physician and the patient
• For inpatient count total for the day of
  counseling, coordination of care and time on
  floor in care of the patient

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Visit levels based on time (cont)

• The note must include a description of the
  counseling and treatment planning
• The physicians coding card contains minimum time
  requirements for each visit level
• Note that the minimum times are different for
  each of the three categories of visits consults,
  new patient and established patient
• Click on this link for additional time-based
  billing information

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Modifier 25

• Append a modifier 25 to an EM code if a
  significant, separately identifiable EM service
  is performed by the same physician on the same
  day as a procedure or other service
• The patients condition must require EM services
  above and beyond what would normally be performed
  in the provision of the procedure
• The necessity for the EM service may be prompted
  by the same diagnosis as the procedure
• A new patient EM service is considered separate
  from the same day surgery or procedureno 25
  modifier needed

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Modifier 25

• For an established patient, if the EM service
  results in the initial decision to perform a
  minor procedure (0-10 days global period) on the
  same day and medical necessity indicates an EM
  service beyond what is considered normal protocol
  for the procedure, the 25 modifier is appropriate
• To determine the correct level of EM service to
  submit, identify services unrelated to the
  procedure and use as EM elements
• The modifier 25 should be appended in the
  modifier field on the level of service in Epic.

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Modifier 59

• Modifier 59 (distinct procedural service) is
  being split into 4 new modifiers accepted by
  Medicare effective 1/1/2015. The new modifiers
  are
• -XE Separate encounter (services that are
  separate because they take place during separate
  encounters)
• -XS Separate structure (Performed on different
  anatomic organs, structures or sites)
• -XP Separate practitioner (services are distinct
  because different practitioners perform them)
• -XU Unusual non-overlapping services (services
  that are distinct because they do not overlap the
  usual components of the main service)
• Beginning with date of service 1/1/2015, if you
  assign a -59 modifier, also assign the
  corresponding X modifier. The system will make
  sure that the correct modifier gets to the
  correct insurance carrier.

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3. Teaching physician (TP) rulessupervision of
residents and billing Medicare and Medicaid
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Medicare TP Attestation Requirement

• The 11/22/02 revisions to the regulations provide
  that, for EM services, the TP does not have to
  duplicate any resident documentation
• The TP must be present during the key portions of
  the service and personally document his or her
  presence.
• The resident note alone, the TP note alone or a
  combination of the two may be used to support the
  level of service billed
• Documentation by a resident of the presence and
  participation of the TP is not sufficient
• Documentation may be dictated and typed, or a
  computer statement initiated by the TP

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Medical Student Involvement in EM Services and
Documentation Requirements

• The documentation of an E/M service by a student
  that may be referred to by the teaching physician
  is limited to documentation related to the review
  of systems and/or past family/social history.
• Any contribution and participation of a medical
  student to the performance of a billable service
  (other than the review of systems and/or past
  family/social history which are not separately
  billable) must be performed in the physical
  presence of a teaching physician or a resident.
• The teaching physician or resident must verify
  and redocument the history of present illness,
  perform and redocument the physical exam and
  medical decision making.
• These regulations are found http//www.cms.gov/Re
  gulations-and-Guidance/Guidance/Transmittals/downl
  oads/R2303CP.pdf

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Medicare Exception for Primary Care

• CMS does not require direct patient contact for
  primary care, lower-level visits provided by
  residents with more than six months training
  working in approved primary care programs
• Approved primary care centers at UNC
• Family Medicine
• General/Internal Medicine
• General Pediatrics
• Womens Primary Health
• Med Geriatrics
• For Addl Information Primary Care Exception

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Medicare Supervision Guidelines for Procedures
Performed with Residents

• TP must be present during critical and key
  portions immediately available throughout
  surgical procedures and endoscopic operations
• TP decides what portions are key
• If present entire time, the residents note can
  attest to that
• If present for key portions only, TP must
  document extent of involvement
• Two overlapping surgeries
• Key portions must happen at different times
• Must be available to return to either

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Medicare Supervision Guidelines for Procedures
Performed with Residents

• Minor procedures of lt5 minutes
• Must be present the entire time
• Endoscopies (other than surgical operations)
• TP must be present for entire viewing, including
  insertion and removal

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Medicare Supervision Guidelines for Supervision
of Specific Procedures

• Radiology/Diagnostic Tests
• Image and resident interpretation must be
  reviewed by TP to be billable
• TP may sign acknowledging agreement or edit a
  co-signature only is insufficient
• Psychiatry
• TP presence requirement met by concurrent
  observation of the service by video or one-way
  mirror
• Must be present for entire period of time billed
  if psychotherapy code is used

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Medicare Supervision Guidelines for Specific
Procedures

• Time-based procedures billed on TP time only
• Critical care
• Hospital discharge day management
• Prolonged services
• Care plan oversight
• EM counseling/coordination of care
• Specific complex or high-risk procedures require
  continual personal TP supervision
• Interventional radiologic/cardiologic codes
• Cardiac cath, stress tests, transesophageal
  echocardiogram

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Medicare Supervision Guidelines for Critical Care

• Only the teaching physician time may be counted
  toward critical care time. A combination of the
  TPs documentation and the residents documenting
  may support the critical care service.
• The teaching physician medical record
  documentation must provide the following
  information 
• time the teaching physician spent providing
  critical care, 
• that the patient was critically ill during the
  time the teaching physician saw the patient, 
• what made the patient critically ill and 
• the nature of the treatment and management
  provided by the teaching physician.  The medical
  review criteria are the same for the teaching
  physician as well as for all physicians.
• This attestation will meet the TP requirements
  for billing to Medicare.
• Patient is critical with ______. I spent ___
  minutes while the patient was in this condition
  providing ______. I reviewed the residents
  documentation and I agree with the residents
  assessment and plan of care.

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Medicaid Requirements

• Medicaid requires that the TP be
  "immediately available" to the resident and
  patient and use "direct supervision" for
  procedures. Direct supervision does not
  necessarily mean that the TP must be present in
  the room when the service is performed. The
  degree of supervision is the responsibility of
  the TP and is based on the skill, level of
  training and experience of the resident as well
  as the complexity and severity of the patient's
  condition. Written documentation in the medical
  record for Medicaid patients must clearly
  designate the supervising physician and be signed
  by that physician.

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Where To Get Help

• www.med.unc.edu/compliance/
• UNC FP Professional Coderscode inpatient
  services and some outpatient procedures. (See
  your division manager for your coders name.)
• UNC FP Compliance Office procomplianceUNCHC_at_unche
  alth.unc.edu
• Laura Bushong, CPC, CEMC, Associate Director UNC
  FP Compliance
• Tracy Rentner, FNP, CPC, Compliance Consultant
• Dana Sheffield, CPC, Senior Compliance Analyst
• Kimberly Thompson, CPC, COC, Compliance Analyst
• Confidential Help Line 800-362-2921
• AMA CPT Manual