Non-Physician Practitioner Services Coding & Reporting. Karla R. Peter, RHIT, CCS, CCS-P, CPC Avera Health September 6, 2013

Full text

(1)

Non-Physician Practitioner

Services – Coding & Reporting

Karla R. Peter, RHIT, CCS, CCS-P, CPC

Avera Health

(2)

Medical Necessity – Overarching

Criterion

n Medicare Claims Processing Manual, Chapter 12

states,

q “Medical necessity of a service is the overarching criterion

for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or

appropriate to bill a higher level of evaluation and

management service when a lower level of service is

(3)

Evaluation & Management (E/M)

Service

n

What is an E/M service?

q Typically, a face-to-face encounter with a patient

for the purpose of diagnosing and/or treating one or more acute or chronic problems that the patient is experiencing.

q E/M services involve:

n Taking a patient’s history; n Doing a physical exam; and,

(4)

E/M Documentation Guidelines

n

1995 versus 1997 (General Multi-System &

Single Organ System)

q 1995 Documentation Guidelines

n http://www.cms.hhs.gov/MLNProducts/Downloads/1995

dg.pdf

q 1997 Documentation Guidelines

(5)

E/M Code Selection - Seven

Components

n

History

n

Examination

n

Medical Decision-Making

n

Counseling

n

Coordination of Care

(6)

E/M Code Selection - Key Components

n

History

q Chief Complaint

q History of Present Illness (HPI) q Review of Systems (ROS)

q Past, Family, Social History (PFSH)

n

Examination

n

Medical Decision-Making (MDM)

(7)

E/M Key Components –

Extent Performed & Documented

n History

q Problem-Focused (PF)

(8)

History – Chief Complaint

n

A concise statement describing the

symptom, problem, condition, diagnosis, or

reason for the patient’s visit.

(9)

History – History of Present Illness

n A chronological description of the development of

the patient’s present illness from the first symptom to the present time.

n Must be documented by the billing provider.

q CC, ROS, and PFSH may be Recorded by Someone Other

than the Billing Provider

n Includes elements such as Location, Quality,

Severity, Timing, Context, Duration, Modifying

(10)

History – Review of Systems

n An inventory of body systems obtained through a

series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

n Includes 14 Systems (i.e., Eyes, Cardiovascular,

Respiratory, Allergic/Immunologic, etc.)

q “All Others Negative”

(11)

History – Past, Family and/or Social History

n Past History

q Past experiences with illnesses, treatments

n Family History

q Review of medical events in patient’s family, including diseases

that place the patient at risk

n Social History

q Age-appropriate review of past and current activities

n May be Documented by Someone Other than the Billing Provider n Referring to ‘Old Records’ – Document Specific Date so that Record

(12)

1995 Examination

n

Body Areas Versus Organ Systems

n

Documentation Guidelines

q Comprehensive – General multi-system

examination should include findings about 8 or more of the 12 organ systems.

q Problem Focused (PF), Expanded Problem

(13)

1997 Examination

n

Problem Focused (PF)

q 1-5 elements identified by a bullet in one or more

areas/systems

n

Expanded Problem Focused (EPF)

q At least 6 elements identified by a bullet in one or

(14)

1997 Examination

n Detailed

q At least 6 organ systems/body areas. For each

system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected; or

q At least 12 elements identified by a bullet in two or more

systems/areas

n Comprehensive

q At least 9 organ systems/body areas. For each

(15)

Medical Decision-Making

n

Refers to the complexity of establishing a

diagnosis and/or selecting a management

option as measured by:

q Number of possible diagnoses and/or number of

management options;

q Amount and/or complexity of the data obtained;

and

(16)

Number of Diagnoses or

Management Options

n

Based on the number and types of problems

addressed during the encounter

q Established/New q Stable/Worsening

(17)

Amount and/or Complexity

of Data Reviewed

n

Based on the types of diagnostic testing

ordered or reviewed, the decision to review

old records or obtain history from sources

other than the patient

q Labs, x-rays, discussing tests with the performing

physician, reviewing old records, independent

(18)

Risk of Significant Complications

n

Based on the risks associated with the

presenting problem(s), diagnostic

procedure(s), and possible management

options

q Concurrent conditions q Medications

(19)

Three

Key

Components –

1995 Versus 1997

n

History

q 1995 Versus 1997 – One Exception

n

Examination

q 1995 Versus 1997 – Various Differences q 1995 – EPF Versus Detailed

q 1997 – General Multi-System Versus Single

Organ System

q Vital Signs

n

Medical Decision-Making

(20)

E/M Code Categories

n

Used to Report Professional Services in a

Variety of Settings

q Office or Other Outpatient Services (Office Visits)

n New Patient Versus Established Patient

q Hospital Inpatient Services q Nursing Facility Services

(21)

“New” Patient – CPT Definition

n

New Patient – One who has not received

any professional services from the

physician or another physician of the same

specialty who belongs to the same group

practice, within the past three years.

q Concept does not apply to all E/M code

categories (i.e., ED)

q Definition of same group practice

(22)

“Established” Patient – CPT Definition

n

Established Patient – One who has received

professional services from the physician or

another physician of the same specialty who

belongs to the same group practice, within

the past three years.

q Any professional service means a face-to-face

service by the physician/provider

q Does not include diagnostic interpretations (i.e.,

(23)

Office Visits – New Patient

Requires 3 of 3 Key Components:

n 99201

q PF History, PF Exam, Straightforward MDM

n 99202

q EPF History, EPF Exam, Straightforward MDM

n 99203

q Detailed History, Detailed Exam, Low Complexity MDM

n 99204

q Comprehensive History, Comprehensive Exam, Moderate

Complexity MDM

n 99205

q Comprehensive History, Comprehensive Exam, High Complexity

(24)

Office Visit – Established Patient

Level 99211

n

No Specific Requirements of Key

Components

(25)

Office Visits – Established Patient

Requires 2 of 3 Key Components:

n

99212

q PF History, PF Exam, Straightforward MDM

n

99213

q EPF History, EPF Exam, Low Complexity MDM

n

99214

q Detailed History, Detailed Exam, Moderate

Complexity MDM

n

99215

q Comprehensive History, Comprehensive Exam,

(26)

Hospital Inpatient Services –

Initial Hospital Care

Requires 3 of 3 Key Components:

n 99221

q Detailed or Comprehensive History, Detailed or Comprehensive

Exam, Straightforward or Low Complexity MDM

n 99222

q Comprehensive History, Comprehensive Exam, Moderate

Complexity MDM

n 99223

q Comprehensive History, Comprehensive Exam, High Complexity

(27)

Hospital Inpatient Services - Subsequent Hospital Care

n Requires 2 of 3 Key Components:

q 99231

n PF Interval History, PF Exam, Straightforward or Low Complexity

MDM q 99232

n EPF Interval History, EPF Exam, Moderate Complexity MDM

q 99233

n Detailed Interval History, Detailed Exam, High Complexity MDM

q Per CPT, an Interval History “focuses on the period of time since

the physician last performed an assessment of the patient”.

q Patient’s condition is key (i.e., 99231 – “Usually, the patient is

(28)

Hospital Inpatient Services – Hospital

Discharge Day Management

n

E/M Codes 99238-99239

q

No Specific Requirements of Key Components

q

Report Based on Time

(29)

Nursing Facility Services –

Initial Nursing Facility Care

Requires 3 of 3 Key Components:

n Used for patients in SNF’s, ICF’s or LTCF’s n 99304

q Detailed or Comprehensive History, Detailed or

Comprehensive Exam, Straightforward or Low Complexity MDM

n 99305

q Comprehensive History, Comprehensive Exam, Moderate

Complexity MDM

n 99306

q Comprehensive History, Comprehensive Exam, High

(30)

Nursing Facility Services –

Subsequent Nursing Facility Care

Requires 2 of 3 Key Components:

n 99307

q PF Interval History, PF Exam, Straightforward MDM

n 99308

q EPF Interval History, EPF Exam, Low Complexity MDM

n 99309

q Detailed Interval History, Detailed Exam, Moderate Complexity

MDM

n 99310

q Comprehensive Interval History, Comprehensive Exam, High

(31)

Emergency Department Services

n

Emergency Department - CPT Definition

q An organized hospital-based facility for the

provision of unscheduled episodic services to patients who present for immediate medical attention.

n

New and Established Patient Designations

Do Not Apply

(32)

Emergency Department Services

No Delineation Between New or Established Patients

Requires 3 of 3 Key Components:

n 99281

q PF History, PF Exam, Straightforward MDM

n 99282

q EPF History, EPF Exam, Low Complexity MDM

n 99283

q EPF History, EPF Exam, Moderate Complexity MDM

n 99284

q Detailed History, Detailed Exam, Moderate Complexity MDM

(33)

Consultations - Office or Other

Outpatient

n Requires 3 of 3 Key Components

q 99241

n PF History, PF Exam, Straightforward MDM

q 99242

n EPF History, EPF Exam, Straightforward MDM

q 99243

n Detailed History, Detailed Exam, Low Complexity MDM

q 99244

n Comprehensive History, Comprehensive Exam, Moderate

Complexity MDM

q 99245

(34)

Consultations - Inpatient

n Requires 3 of 3 Key Components

q 99251

n PF History, PF Exam, Straightforward MDM

q 99252

n EPF History, EPF Exam, Straightforward MDM

q 99253

n Detailed History, Detailed Exam, Low Complexity MDM

q 99254

n Comprehensive History, Comprehensive Exam, Moderate

(35)

Pre-Operative Clearance

n Consultation or Office Visit E/M?

q Potential for either

n 99241-99245 (Outpatient Consults) n 99201-99215 (Office visits)

n Consultation is a type of service provided by a physician or

non-physician practitioner (NPP) whose opinion or advice regarding

evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

q NPPs may report consultation codes

n Request for clearance was of the NPP n Request for clearance was of the group

n Within state scope of practice/licensure requirements

(36)

Consultation Documentation Criteria

n Consultation Criteria q Request

n Request documented in patient’s record by consulting provider n Included in the requesting practitioner’s plan of care

q Reason/Need

n Reason/Need for consultation documented

q Recommendation

n Documentation of findings/opinion, as well as services ordered or

(37)

Preventive Medicine Services

n

New Patient = E/M Codes 99381-99387

n

Established Patient = E/M Codes

99391-99397

(38)

Preventive Medicine Services

n

Preventive Medicine Service Only

n

Preventive Medicine Along with a Separate

E/M Service

(39)

Preventive Medicine Services

n Preventive Medicine services include:

q Comprehensive history and exam

q Anticipatory guidance and risk factor reduction

q Ordering of appropriate immunizations, lab/diagnostic procedures q Treatment/management of insignificant problems

n CPT definition:

q Comprehensive preventive medicine evaluation and management of

an individual including an age and gender appropriate history,

examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s),

(40)

Preventive Medicine Services

n

Comprehensive History

q Does not include:

n Chief complaint or present illness

q i.e., Not Problem-Oriented

q Does include:

n Comprehensive system review and PFSH n Comprehensive assessment of risk factors

n

Comprehensive Examination

(41)

Preventive Medicine and

Problem-Oriented Visits

n

Reporting an Office Visit E/M with Preventive

Medicine E/M

q Ideally, the HPI describes the patient’s current

problem/symptom

q Require additional work to perform the key

components

q Must be significant and separately identifiable

(42)

Preventive Medicine - Medicare

n Medicare does not pay for “routine” physicals

q Service paid by patient

n Advance Beneficiary Notices of Non-Coverage

(ABN) is not required

q Routine physicals are statutorily excluded/non-covered q May choose to use Notice of Beneficiary Exclusion from

Medicare Benefits (NEMB)

n http://www.cms.hhs.gov/BNI/Downloads/CMS20007English.p

(43)

E/M Code Selection, Time-Based

n

May assign level based on time when

counseling and/or coordination of care

dominates (more than 50%) the

physician/patient encounter

n

Documentation must include:

q Total Duration of Visit

q Amount of time spent in Counseling and/or

Coordination of Care

(44)

Prolonged Services

n

Provider goes above and beyond in the

length of time spent with a patient

n

Documentation

q Duration and content of the E/M service and

prolonged service n Be specific

(45)

Prolonged Services

n

Prolonged Physician Service With Direct

(Face-to-Face) Patient Contact

q Add-on codes 99354-99357

q Less than 30 minutes

n Do not report

(46)

Prolonged Services - Outpatient

n Prolonged physician service in the office or other

outpatient setting requiring direct (face-to-face) patient contact beyond the usual service;

q +99354 – first hour

n (List separately in addition to code for office or other outpatient

E/M service)

q +99355 – each additional 30 minutes

n (List separately in addition to code for prolonged physician

service)

(47)

Prolonged Services - Inpatient

n Prolonged physician service in the inpatient or

observation setting, requiring unit/floor time beyond the usual service;

q +99356 – first hour

n (List separately in addition to code for inpatient E/M service)

q +99357 – each additional 30 minutes

n (List separately in addition to code for prolonged physician

service)

n 15-minute rule

(48)

Prolonged Services

n Total duration of all direct face-to-face service

(including the visit) must equal or exceed the threshold time

q Typical time plus 30 minutes

n Threshold time

q www.cms.gov/manuals/downloads/clm104c12.pdf

q Codes 99355 and 99357

(49)

Prolonged Services w/Time-Based Services

n

Time-based reporting

q Counseling/coordination of care dominates q Description of counseling/coordination of care

q Time documented

n Duration of counseling/coordinating care n Total duration of the visit

n

Prolonged services may only be reported with

(50)

Prolonged Services Without Direct

(Face-to-Face) Contact

n

Prolonged E/M service before and/or after

direct (face-to-face) patient care

q 99358 first hour

q +99359 each additional 30 minutes

n Must relate to:

q service or patient where direct (face-to-face) care has

occurred or will occur

(51)

Global Periods

n

Major Procedures/Surgeries

q 90-day global

q Includes E/M service on the day before and day

of procedure

n

Minor Procedures/Surgeries

q 0- and 10-day global

q Includes E/M service on the same day as

(52)

Global Surgical Package

n Pre-operative visits

q After decision is made to operate

n Intra-operative services

n Complications following surgery (Medicare)

q Complications not requiring a return trip to the OR

n Post-operative visits

q Post-op visits related to recovery from surgery

(53)

Services Not Included in the Global

Surgical Package

n

Initial evaluation to determine need for

surgery

n

Visits unrelated to the diagnosis for which

surgery was performed

n

Diagnostic tests/procedures

n

Clearly distinct surgical procedures during

the post-op period

q i.e., Staged Procedures

n

Treatment for post-op complications

(54)

CMS-1500 Claim Form

n

Medicare Claims Processing Manual

q Chapter 26

q http://www.cms.hhs.gov/manuals/downloads/clm

104c26.pdf

n

Consultation Services

(55)

CMS-1500 Claim Form, Continued

n Box 21 – Diagnosis or Nature of Illness or Injury

q Diagnoses relevant to the visit

n Box 24b – Place of Service

q 11 – Office

q 21 – Inpatient Hospital q 22 – Outpatient Hospital

q 23 – Emergency Room - Hospital q 31 – Skilled Nursing Facility

q 32 – Nursing Facility

n Medicare Claims Processing Manual, Chapter 12,

(56)

Place of Service (POS) Codes

n

These codes are used on professional claims

to specify the entity where the service was

rendered.

n

Individuals payers may have reimbursement

(57)

Additional Place of Service (POS)

Codes

n

03 – School

n

09 – Prison/Correctional Facility

n

12 – Home

(58)

CMS-1500 Claim Form, Continued

n

Box 24d – Procedures, Services, or

Supplies

n

Box 24e – Diagnosis Pointer

(59)

ICD-9-CM Diagnosis Coding

n

Reported Diagnoses Must be Substantiated by

Provider Documentation

n

Symptom Coding

n

Coding Diagnoses Documented as

(60)

ICD-9-CM Diagnosis Coding,

Continued

n

Acute versus Chronic Conditions

n

Anemia

q Chemotherapy-Induced

q Acute Blood Loss

n

Coronary Artery Disease/Arteriosclerotic

(61)

ICD-10-CM & ICD-10-PCS

n

ICD-10-CM – Diagnosis Codes

n

ICD-10-PCS – Procedure Codes

n

Level of Detail

(62)

Resources

n

Medicare Claims Processing Manual – 100-4

(63)

Resources, Continued

n National Government Services – Medicare

q http://www.ngsmedicare.com/

n Wisconsin Physician Services – Medicare

q http://www.wpsmedicare.com/

n Noridian Administrative Services - Medicare

(64)

Resources, Continued

n 1995 Documentation Guidelines

q www.cms.hhs.gov/MLNProducts/downloads/1995dg.pdf

n 1997 Documentation Guidelines

(65)

Questions

n

Any Questions?

n Karla R. Peter

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