Best Practices in Billing and Coding. Janet Bull, MD, FAAHPM, HMDC Four Seasons

Full text


Best Practices in Billing and




o Salix Pharm – Scientific Advisory Board



o The information enclosed was current at the time it was prepared for presentation.

Medicare and other payer policy change frequently; links to the source documents have been provided for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

o Although every reasonable effort has been made to assure the accuracy of the

information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

o This presentation is a general summary that explains certain aspects of the




Understand the auditing process


Understand the basics of billing by



Discuss when to use time vs complexity in



Gain an understanding of the importance of


What is our current reality?

o OIG 2014 Work Plan

Focus on Medicare Physician Part B

Focus on GIP level of care

Focus on duplicative billing for


Audit Triggers

o Random Sampling – CMS is required to audit 10%

of its providers

o Focused Medical Review – each quarter Medicare

reviews specific CPT codes and figures the mean for each of the codes – looks for outliers

o Complaints by staff – False Claims Act o Patient complaints – required by law to


Audit Triggers


High number of billings per provider


Overutilization of one procedure code


Failure to collect the co-pay for Medicare


Submitting “unspecified” diagnosis on a

consistent basis


Recent 99233 Probe – Error Rate

o NC – 45% CDR o SC – 47% CDR o VA – 45% CDR o WVA – 52% CDR Incomplete or no documentation – 70% Down coded – 15% Illegible – 7%


And recognize….


Documentation must support coding and


If it’s not documented, “wasn’t done”

If it’s not legible – it doesn’t count


Coding is determined by…


Who are you?


Who is the patient?


Where is the patient?


Time or complexity?


Who are you?

o Hospice employed physician? o Hospice contracted physician?

o Not hospice employed physician who is hospice


o Not hospice employed physician who is

consulting” physician?


Hospice Provider Billing – AOR *

o Direct patient care related to terminal diagnosis If MD employed/contracted by hospice → Hospice

bills Medicare Part A. Billings paid at 100% rate by MAC (ie, Palmetto)

If MD not employed by hospice – bill Medicare

part B with a GV modifier

IF NP acting as attending (patient must be

informed and choose NP) → Medicare Part A Billings paid at 85% of physician rate


Hospice Attending of Record


If AOR Not employed/contracted by hospice

they bill Medicare Part B

Use GV modifier – if care related to hospice

Use GW modifier – if care unrelated to hospice

Can bill for Care Plan Oversight


Care Plan Oversight by PMD


Covers a 30-day period


Review of care plan, etc.


Only billable by attending physician not

employed by hospice


Activities and time spent must be



CPT code 99377: 15-29 minutes/month


Palliative Care Provider Billing

o All billings → Medicare Part B

o Billings paid based on physician fee schedule

Medicare pays 80% of allowable

o Must show additional 20% billed to patient or


o NP/PA receive 85% of physician rate o Can bill as attending or consulting

o Need order for PC consult (hospital and NH) o Paid by the MACs (Medicare Administrator



Who are you?


Who is the patient?


Where is the patient?


How should I bill? Complexity or Time?


Who is the Patient?

o New – patient has not been seen by the physician

or the physicians in the same sub specialty group within the past 3 years.

o Established – patient has received face to face

service from the physician or member of the physicians’ group within 3 years.

Example: Patient discharged from PC seen 2 years later in the clinic setting – established pt


Quiz Time

A hospice consult is requested on a COPD patient who has been discharged home after a prolonged hospitalization for respiratory crisis. Patient was followed by the palliative care team in the hospital. Hospice admits and physician visits patient at their home and performs a 90 minute H&P

 Both HPC care teams are employed by the same organization and use the same tax ID status.


And the answer is….


Bill new home patient – 99345


Bill established home patient – 99350


Bill established patient with prolonged

service code – 99350 + 99354



Who are you?


Who is the patient?


Where is the patient?


How should I bill? Complexity or Time?


Location Determines CPT Code


Inpatient Skilled Nursing Home/

Hospital/GIP Hospice

Initial vs. Subsequent




Inpatient Billing


Hospital, SNF, GIP IPU

Initial – as of 1/2010 this code is used by



physician, AND the


, since there are no consultant

codes. Attending uses modifier – AI


Outpatient Billing


Home, ALF, Domiciliary, Clinic or Office


New – first visit by physician within 3 years

of being seen by anyone in the practice


Skilled Nursing Facility

o Bill initial codes (99304-6) in the Nursing Home o If Admitting Physician - use the modifier – AI

o Most Skilled Nursing Facilities require a physician

to be the Attending (cannot use mid-levels as attending)

o Nurse practitioners can now bill initial patient



Who are you?


Who is the patient?


Where is the patient?


How should I bill? Complexity or Time?



What are you currently basing your coding on - time or complexity?

A. 100% time

B. 100% complexity C. > 50% time

D. > 50% complexity


Types of Coding


There are two methods for determining

CPT Levels

Intensity (Component or Element coding)



Time vs. Complexity

o Need to understand both well

o Common mistake is to just bill on time

o When >50% time is spent in coordination and

counseling, time code should be used. (face to


Complexity Trumps Time

o If you complete a complex visit and fulfill/exceed

all the key components in less than the typical time – you still bill at the higher code.

o Example - Subsequent hospital care

99232 typically 25 minutes

99233 typically 35 minutes


Evaluation & Management Codes

First, determine which CPT E&M code to use Location of the patient

New vs. Established (outpatient)

Initial vs. Subsequent (inpatient)

Then choose right “level” of service

Most often at levels 3, 4 or 5 in our world

Based on documentation of Key Components:

1. History

2. Exam, and

3. Medical decision making



Billing by Complexity

Key elements in selection of level

o History

Problem focused

Expanded problem focused Detailed



Key Component 1: History

History =



Review of Systems


past hx, past family, past social


Component 1 – History/HPI

a. Chief Complaint (Reason for Visit) is required at all levels (establishes medical necessity)

b. History of Present Illness (HPI):

Status of 3 Chronic problems OR


1. Location – body area

2. Quality – sharp, burning, deep

3. Severity – intensity of illness

4. Duration – how long symptoms last

5. Timing – relation to events

6. Modifying factors – precipitating or alleviating factors


Chief Complaint

o Concise statement describing symptoms, problems,

condition, physician recommended return, or other factor that is the reason for the encounter.

o Chief complaint must be explicitly stated or easily

inferred from documentation:

“Severe abdominal pain for past 8 hours” (explicit) ”Follow up on medication adjustment”

o Gives a reason for the visit – helps to establish the


History of Present Illness

o Chief Complaint is required at all levels Reason for the encounter/visit

Supports the medical necessity

o History of Present Illness elements: Location – body area

Quality – sharp, burning, deep

Severity – intensity of illness

Duration – how long symptoms last

Timing – relation to events

Modifying factors – precipitating or alleviating factors


Selecting Level of History


Brief (1-3 elements) n/a n/a Problem Focused Brief (1-3 elements) Problem Pertinent

(system directly related to problem identified in HPI)

N/A Expanded Problem Focused

Extended (4 or

more elements)

Extended (system directly related to problem

identified in HPI & a

limited # of add’l systems - 2-9 total Pertinent (1 or all 2 of the PFSH depending on E/M category) Detailed Extended (4 or more elements)

Complete (system directly related to problem

identified in HPI + all add’l systems or a minimum of 10 systems) Complete (2 or all 3 of the PFSH depending on E/M category) Comprehensive


ROS Guidelines

Complete = ten (10) systems

Documentation should include:

o Patient’s pertinent positive and negative responses

Must be documented for each system related to the problem

Those systems with positive or pertinent negative responses must be individually documented

o For the remaining systems, a notation indicating “all other


Component 1 – History/Review of Systems

Constitutional Eyes

Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic ROS – Pertinent (1), Extended (2-9)


Component 1 –

History/Past, Family and

Social History

Consists of:

Past medical history (the patient’s past experiences with illnesses, operations, injuries and


o Family history (a review of medical events in the

patient’s family, including diseases which may be hereditary or place the patient at risk)

o Social history (an age appropriate review of past

and current activities – smoking, alcohol, work risks).


Component 2 =

Physical Exam

1995 Guidelines

o Comprehensive: Gen’l multi-system (8+ OS/BA) or

complete single system organ system exam.

Body Areas:

•Head, including face •Neck

•Chest, incl. breasts & axillae •Abdomen

•Genitalia, groin, buttocks •Back, incl. spine

•Each extremity

Organ Systems:

•Constitutional •Eyes


Component 2 - Exam

Problem Focused A limited exam of the affected body area or organ system (1+ BA/OS)


problem focused

A limited exam of the affected body area or organ system and any other

symptomatic/related area(s)/system(s)

(2-7 BA/OS)

Detailed An extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related area(s)/system(s)

(2-7 BA/OS) – more detailed


Component 3 – Complexity of

Medical Decision Making

Complexity of Medical Decision-Making:

Risk assessment

Data ordered or reviewed



Level of Risk

Presenting Problems Diagnostic Procedures Ordered Management Options Selected

Minimal Level I - II

*One self-limited problem, e.g., cold, insect bite, tinea corporis

*Lab tests requiring venipuncture *Chest X-rays


*Ultrasound [e.g., echocardiography] *KOH prep *Rest *Gargles *Elastic Bandages *Superficial Dressings Low Level III

*Two or more self-limited or minor problems

*One stable chronic illness [e.g., well-controlled hypertension or non-insulin-dependent diabetes, cataract, BPH] *Acute uncomplicated illness or injury [e.g., cystitis, allergic rhinitis, simple sprain

*Physiologic tests not under stress [e.g., pulmonary function tests]

*Non-cardiovascular imaging studies with contrast [e.g., barium enema]

*Superficial needle biopsies

*Clinical lab tests requiring arterial puncture *Skin biopsies

*Over-the-counter drugs

*Minor surgery with no identified risk factors *Physical therapy

*Occupational therapy *IV fluids without additives

Moderate Level IV

*One or more chronic illnesses with mild exacerbation, progression or side effects of treatment

*Two or more stable chronic illnesses *Undiagnosed new problem with uncertain prognosis [e.g., lump in breast]

*Acute illness with systemic symptoms [e.g., pyelonephritis, pneumonitis, colitis] *Acute uncomplicated injury [e.g., head injury with brief loss of consciousness]

*Physiologic tests under stress [e.g., cardiac stress test, fetal contraction stress test] *Diagnostic endoscopies with no identified risk factors

*Deep needle or incisional biopsy

*Cardiovascular imaging studies with contrast and no identified risk factors [e.g.,

arteriogram, cardiac catheterization] *Obtain fluid from body cavity [e.g., lumbar puncture, thoracentesis, culdocentesis]

*Minor surgery with identified risk factors *Elective major surgery [open, percutaneous or endoscopic] with no identified risk factors *Prescription drug management

*Therapeutic nuclear medicine *IV fluids with additives

*Closed treatment of fracture or dislocation without manipulation

High Level V

*One or more chronic illnesses with severe exacerbation, progression or side effects of treatment

*Acute or chronic illnesses or injuries that may pose a threat to life or bodily function [e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness w/potential threat to self or others, peritonitis, acute renal failure *An abrupt change in neurologic status [e.g., seizure, TIA, weakness or sensory loss]

*Cardiovascular imaging studies with contrast with identified risk factors

*Cardiac electrophysiologic tests *Diagnostic electrophysiologic tests

*Diagnostic endoscopies with identified risk factors


*Elective major surgery [open, percutaneous or endoscopic] with identified risk factors

*Emergency major surgery [open, percutaneous or endoscopic]

*Parenteral controlled substances

*Drug therapy requiring intensive monitoring for toxicity

*Decision not to resuscitate or to de-escalate care because of poor prognosis


Complexity of

Medical Decision Making

Risk Data Dx/Mgt MDM

Low 2 2 low

Mod 3 3 mod

High 4 4 high


Coding Using Components






Coding Pearls


Chief complaint – reason for visit


Hx, Exam & MDM –

all subsequent visits and

established visits

only need 2 out of 3 key

components to bill for a particular level of care


HPI – all subsequent visits only need interval

history (no need for PMH, SH, FH)


The most important component is medical


Extender codes

o The Prolonged Physician Service with Direct Patient

Contact series (99354-99357) are used when a

physician provides prolonged service involving direct (face to face) patient contact that is beyond the usual service (typical time) in either the inpatient or

outpatient setting.

o The prolonged time does not have to be continuous

but in-out times must be recorded

o Each code is reported separately in addition to


Prolonged Service Codes

o Inpatient – 99356

Companion code to E/M

Use for first 30 min over time threshold Direct face to face time (CPT – floor time)* Each additional 30 beyond 45 min - 99357 o Outpatient – 99354

Companion code to E/M Direct face to face time

Each additional 30 min beyond 45 min - 99355


Quiz Time

o Subsequent hospital visit for lung ca pt with

nausea. You spent 10 min reviewing notes, 15 min obtaining detailed GI history, and 5 min with exam. You diagnose gastroparesis and spend 25 minutes discussing etiology/ treatment . Bill? Total time 55 min

A. Time based billing – 99233 + 99356

B. Complexity based with extender 99232+99356 C. Complexity visit 99232

Subsequent visit codes 99231 – 15 min


Quiz Time

o Time vs Complexity – 99232 base code (typical

time 25 min)

o Total time = 55 min <50% counseling o Time over base code 55-25 = 30

o Bill extender code since 30 min over threshold (25


Time Based Coding

50% rule > 50% time spent in coordination

and counseling of care

Documentation required about how time


Providing detail via a checklist:

Counseling may include discussion of:

Diagnostic results, impressions, and/or recommended

diagnostic studies


Risks and benefits of management or treatment choices

Instructions for management (treatment and/or follow-up)

Importance of compliance with chosen management

(treatment) options

Treatments initiated or adjusted

Risk factor reduction

Patient and family education

Must documented the time and how it was spent

And MUST say “more than 50% of [___amount] of time was spent


What is time?

o “Time” is calculated

differently in the hospital and non-hospital settings

o “Floor/unit time” for

institutional setting

o “Face-to-face time”


Time-Based Coding - Outpatient

Face to Face Time for office and other outpatient settings – face-to-face time is defined as only that time which the physician spends face to face with the patient and/or family.

Face-to-Face Time is considered a valid proxy for the total work done before, during, and after the visit. Therefore, Non face-to-face time (pre- and post-encounter time) is NOT included in the time



o The AMA sees F2F with the surrogate as the same

as F2F with the patient

o CMS does not and has not reimbursed for time

that is not F2F with the patient

o This is an example of the CPT definition not being

fully adopted by CMS

o This is also an example of the “Golden Rule” – the


Nuances in HPC Billing


Incident to – Palliative care


Shared/split visit – Palliative care


Concurrent care


Discharge codes


“Incident to” Billing

o Cannot use in the hospital/NH setting

o Initial visit must be performed by physician o Typically used in a clinic or office situation

o Physician must be physically present and act in a

supervisor role

o Reimbursement based on 100% of physician rate


Split/Shared E/M Service

o Hospital Inpatient/Outpatient/ ED Setting

When the E/M is shared between a physician and NPP from

the same group practice, and the physician provides any face-to-face portion of the E/M encounter, service may be billed under either’s PIN/NPI.

Physician documentation of something from at least one

E/M key component.

Can use with PC fellows (billing under attending NPI)


Split/Shared E/M Service

o Office/Clinic Setting

When an E/M service is a shared/split encounter between a physician and a NP/PA the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient. Billing may be done under the physician’s provider number.

If “incident to” requirements are not met, the service must be billed under the NP’s/PA’s


Examples of Shared/Split Visits

o If the NPP sees a hospital inpatient in the morning and the

physician follows with a later face-to-face visit on the same day, physician or NPP may report the service for billing.

• “Patient seen. Breath sounds more distant today. Agree with

above plan. <signature, MD/DO>”

o In the office setting the NPP performs a portion of an E/M

encounter & the physician completes the E/M service. If the

incident to’ requirements are not met, service must be


NPs in Hospice/Palliative Care

o NPs may bill Part A Medicare Hospice and be

reimbursed IF they are listed as the Attending of Record at the time of election.

o NPs typically may not serve as the Attending of

Record in a NH

o NPs can do the face to face encounter which in


PAs in Hospice/Palliative Care

o Cannot be Attending of record for hospice o Cannot ever bill on a hospice patient

o Cannot do the face to face encounter

o Billing in palliative care is the same as NPs – a


Discharge Codes

Codes used to report the total duration of time spent by a Physician for final hospital discharge of a patient.

The codes include, as appropriate, final exam of the patient, discussion of the hospital stay (even if the time spent by the physician on that date is not continuous), instructions for continuing care to all relevant caregivers, and preparations of discharge records, prescriptions and referral forms.

99238 30 minutes or less


CPT on D/C Services

Clarification on Hospital D/C Services (99238/39) from the AMA’s cpt Assistant, November 2009, Volume 19 Issue 11:

Q: Can a physician bill for a hospital death summary if he or she is not present in the hospital at the time of the patient’s death? If yes, what would be the CPT code(s) to report?

A: The hospital discharge services codes may be used to report discharge

services to patients who die during the hospital stay. The attending

physician may be needed to perform the final examination of the patient, discuss the hospital stay with the family members…prepare


Palliative Care Only

o Transition Codes


Transition Codes

o Require communication with patient/CG within 2

business days of discharge

o Includes medication reconciliation

o 99495 – F2F within 14 days of discharge/ pts of

moderate complexity

o 99496 – F2F within 7 days of discharge/high


o Payments about double standard visit o Can only be billed by one provider – one


Chronic Care Management Code

o Two or more chronic conditions with

exacerbations, decompensating, or functional decline.

o Comprehensive care plan established,

implemented, revised, or monitored

o 99490 – 20 min clinical staff time directed by


You caught a virus from your computer


Common Pitfalls - Assumptions

o Most Common Pitfall!

Executive Leadership assumes Physicians know

how to document

“They run their own private practice, they

must know how to do it…”

Documentation from a

coding/documentation compliance


Pearls Regarding Billing

o Gain understanding of most common codes o Use templates for documentation

o Use billing cheat sheets o Have “experts” in house o Develop QAPI


Best Practices in Billing/Coding

o Identify the Internal Experts (you may be surprised) o Identify Physician Champions of Compliance

o Education

For Providers

For admin and billing staff

o Documentation is the Key

Provide Cheat Sheets (trying to teach new tricks!)


o Consider Outside Audit


OIG’s Physician Compliance Guidance

In the Third-Party Medical Billing Compliance

Program Guidance, the OIG recommended that a baseline, or snapshot, be used to enable a practice to judge over time its progress in reducing or eliminating potential areas of vulnerability.

This practice, known as benchmarking, allows a


Compliance Guidance

o The practice’s self-audits can be used to determine


Bills are accurately coded and accurately reflect

the services provided (as documented in the medical records);

Documentation is being completed correctly;

Services or items provided are reasonable and

necessary; and



o What type of quality checks do you have in place?

Assessing physician/NPP documentation

Assessing contract physician documentation

o YOU are billing for these services. Are they being

documented appropriately?

Annual Code Changes

o Changes to coding rules

Annual Rule Changes


What Are You Looking For?

o Evaluation & Management

Consultation vs. Referral

Levels of E/M service

o Can you read it?

o Can you tell who provided the service?


Education Needs

o Recognize the importance of continued education o Educate physicians/NPPs as new hires!

o Regulations change frequently – have a plan to

keep up with changes


Agency Education Needs

o Assign someone to “own”

o Knowledgeable about provider billing


Assessing Providers

o Track code by providers – see who are your

outliers on both ends

o Know the rules for the most frequent E/M codes

you use


Summary Slide

Isn’t this painful?! I need palliation…

Legibly document what you do and how

for how long it takes to do it!

Think Complexity first - but can use time-based

coding given the unique priority of communication in our field

Know when and how to use extender codes Recognize the importance of accuracy in this

area – audit internally for compliance!







Related subjects :