Osteopathic Coding & Billing: An Overview

(1)

Osteopathic Coding & Billing:

An Overview

Douglas J. Jorgensen, DO, CPC, FAAO,

FACOFP, CAQ Pain Medicine

(2)

Agenda

•

Intro

•

HCPCS (CPT) Review

•

ICD-10

•

Charge Setting & Analysis

•

Practice KPI

•

Medicare Par, Non-par, or Opt-out

•

E&M/OMT Coding

(3)

(4)

HCPCS Review: OMT CPT

®

Codes

•

OMT CPT Codes are 98925- 98929

–

M99.00-M99.09 for ICD 10

•

Other manual therapy codes (i.e.,

(5)

HCPCS Review: OMT CPT

®

Codes

•

DC use ‘Treatment Plan’ of defined number of

treatments prior to re-evaluation.

–

Not so for OMT

•

-25 Modifier

(6)

OMT CPT Codes

CPT Codes for OMT

Number of Regions Treated

98925

1-2 Regions

98926

3-4 Regions

98927

5-6 Regions

98928

7-8 Regions

(7)

ICD-10… Your EMR, won’t show you:

•

ICD-10’s two volumes

–

the Alphabetic Index

–

the Tabular List

–

Procedural Code System… not used at CHCs

(8)

ICD-10 Thoughts

•

Duality of ICD-9 & ICD-10… How long

•

Unique terminology

–

Excludes 1 vs. Excludes 2

–

“X” Space holders

–

Laterality

–

Acute & Chronic

–

Sequala(ae)

•

EMR & PM Updated

•

Test, test, test

•

Start summer… not Oct 1

(9)

ICD-10 “X” EXAMPLE

(10)

Answer: L60.0

1. Ingrown toenail, right

great toe

(11)

Answer:

J45.22

2. Mild intermittent asthma,

status asthmaticus

(12)

3. Pneumonia, bacterial, left

upper lobe

(1 of 2)

(13)

Answer:

J15.9

3. Pneumonia, bacterial, left

upper lobe

(2 of 2)

(14)

Answer, Part 1:

H72.91

4. Perforation of tympanic

membrane due to chronic suppurative

otitis media, right ear

(1 of 3)

(15)

membrane due to chronic suppurative

(2 of 3)

(16)

membrane due to chronic suppurative

(3 of 3)

Answer, Part 2: H66.3X1

(17)

5. Type 1 diabetes with diabetic

nephrosis

(1 of 2)

(18)

Answer:

E10.21

5. Type 1 diabetes with diabetic

nephrosis

(1 of 2)

(19)

Answer:

Z00.129

6. Well baby exam, without

abnormal findings, aged 3 months

(20)

Charge Setting

(1 of 2)

•

Payers pay your charge or there fee schedule…

whichever is less

•

Desired Adjustment 30%+

•

Medicare fees = charge floor

•

Underpayment management…

–

Within 10%, too low

•

Prompt payment discount

–

Unilateral application

–

Time value to money

(21)

Charge Setting

(2 of 2)

CPT

Codes

Item Name

Fee in

Dollars

Medicare

Fee

150% of

Medicare

200% of

Medicare

250% of

Medicare

99201

E/M Svc New Pt Level 1 $

80.00

$43.98

$66

$88

$154

99202

110.00

$75.08

$113

$150

$263

99203

E/M Svc New Pt Level 3 $

200.00

$109.05

$164

$218

$382

99204

250.00

$165.90

$249

$332

$581

99205

300.00

$208.45

$313

$417

$730

99211

E/M Svc Est Pt Level 1

$

45.00

$20.02

$30

$40

$70

99212

$

65.00

$43.98

$66

$88

$154

99213

$

85.00

$72.94

$109

$146

$255

99214

$

120.00

$108.34

$163

$217

$379

99215

$

160.00

$146.24

$219

$292

$512

(22)

Charge Analysis

(1 of 2)

CPT

Codes

Item Name

Fee in

Dollars

Medicare

Fee

Percentage of

Medicare

99201

E/M Svc New Pt Level 1

$

80.00

$43.98

181.91%

99202

$

110.00

$75.08

146.50%

99203

$

200.00

$109.05

183.40%

99204

$

250.00

$165.90

150.69%

99205

$

300.00

$208.45

143.92%

99211

$

45.00

$20.02

224.75%

99212

$

65.00

$43.98

147.80%

99213

$

85.00

$72.94

116.53%

99214

$

120.00

$108.34

110.77%

99215

$

160.00

$146.24

109.41%

(23)

Charge Analysis

(2 of 2)

CPT

Codes

Item Name

Fee in

Dollars

Medicare

Fee

Percentage

of Medicare

43262 ERCP w/Sphincterotomy

$

2,395.00

$387.94

617.36%

43264 ERCP w/Removal stones

$

2,610.00

$395.45

660.01%

43266 EGD ENDOSCOPIC STENT PLACE

$

2,610.00

$24.42

10687.96%

43270 EGD LESION ABLATION

$

1,300.00

$777.66

167.17%

43274 ERCP DUCT STENT PLACEMENT

$

2,200.00

$500.57

439.50%

43275 ERCP REMOVE FORGN BODY DUCT

$

1,650.00

$408.32

404.09%

43276 ERCP STENT EXCHANGE W/DILATE

$

2,250.00

$520.95

431.90%

43277 ERCP EA DUCT/AMPULLA DILATE

$

1,660.00

$410.46

404.42%

43760 Change Gastrostomy Tube

$

530.00

$499.85

106.03%

44360 SMALL BOWEL ENTEROSCOPY

$

600.00

$159.11

377.10%

(24)

Key Performance Indicators- KPI

•

DAR/DSO

•

Net AR

•

Encounter Rate

(25)

KPI- DAR/DSO

“This conversation needs to stay between us…”

-CFO of $10M health center

• What is Days of Accounts Receivable (DAR)?

• Example… in a year (365 days)

– $1,000 in charges per day

– $365,000 in annual charges

– If AR = $47,000, DAR = 47 days

• Example… Jan to June Charges = $1,500,000

– Total days (365 divide by 2 (half a year)) = 182.5 days

– Average Daily Charge ($1.5M divided by 182.5) = $8,219.18

– If AR = $723,723 then DAR = this # divided by $8,219.18

– DAR = 88.053 days

(26)

KPI- Net AR

Data Elements

Total Charges:

$

12,345,123.00

Total Payments:

$

5,016,734.29

Total Adjustments:

$

3,764,898.64

Time Period (months):

12

Payments + Adjustments =

$

8,781,632.93

Net AR:

$

3,563,490.07

Total Charges produced less Payments + Adjustments = Net AR

True value of Net AR = Payment Percentage

×

Net AR

(27)

KPI- Encounter Rate

Payments over a fixed fiscal period divided by the

number of visits (patients seen) to achieve those

patients = Encounter Rate

Data Elements

Average Monthly Charges:

$

1,028,760.25

Average Monthly Payments:

$

418,061.19

Average Montly Adjustments:

$

313,741.55

Annual Visits

27,433.61

Monthly Average:

2,286.13

(28)

KPI- Payment Percentage

Payments (Numerator) as a Percentage of Payments plus

Adjustments (Denominator) = Payment Percentage

Payer

Charges

Payments

Adjustments

Payment

Percentage

Anthem BCBS

$

3,086,280.75

$

1,555,187.63

$

941,224.66

62.30%

Cigna

$

1,481,414.76

$

802,677.49

$

451,787.84

63.99%

United Health

$

3,333,183.21

$

1,003,346.86

$

828,277.70

54.78%

Self Pay

$

1,357,963.53

$

752,510.14

$

752,979.73

49.98%

Medicare

$

1,851,768.45

$

702,342.80

$

414,138.85

62.91%

Medicaid

$

1,234,512.30

$

200,669.37

$

376,489.86

34.77%

12,345,123.00

$

5,016,734.29

$

3,764,898.64

57.13%

(29)

The Goal

(30)

(31)

ABNs

•

Advanced Beneficiary Notices

•

CMS-R-131

•

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

(32)

ABNs

•

Advanced Beneficiary Notices

•

Private Payers too…Why?

•

Every time

you perform a non-covered service

–

Accepted assignment/contracted

(33)

A Cash Market

•

Obamacare: High Deductibles

•

What’s applied vs. not?

–

Again…covered vs. not covered

(34)

CMS Form 1490S

Patients Can Submit Claims

•

https://www.cms.gov/Medicare/CMS-

Forms/CMS-Forms/downloads/cms1490s-english-instructions-partb.pdf

(35)

The Cash Conundrum

•

Cash only practice

•

Cash for noncovered services

•

Blended option

(36)

Deductibles

•

Deductibles are applied for covered services

•

PRP/Prolo non-covered

(37)

Deductibles

Total Deductible

$5,000.00

PRP w/ US Guidance

2

$1,000.00

$2,000.00

Diagnostic US

3

$175.00

$525.00

99244

1

$225.00

99214

1

$165.00

99213

1

$120.00

20551

2

$91.00

$182.00

20550

2

$86.00

$172.00

Perceived Amount Met:

$3,389.00

Actual Amount Met:

$1,389.00

(38)

Covered Elements

•

Consults, New and Established Office Visits

•

Osteopathic Manipulation

•

Non-Prolo/Non-PRP Injections (ASU/ASC & CON)

–

AKA Diagnostic…the rationale

•

Diagnostic Imaging

•

Diagnostics

(39)

(40)

Worth of Covered Services

NON-FACILITY

FACILITY

CONVERSION Non-Facility

Facility

HCPCS/CPT

DESCRIPTION

TOTAL RVU

FACTOR

Fee

99204

New Pt E&M

4.64

3.67

$35.7547

$165.90

$131.22

99213

Established Pt E&M

2.04

1.43

$35.7547

$72.94

$51.13

20550

Inj tendon sheath/ligament

1.68

1.20

$35.7547

$60.07

$42.91

20551

Inj tendon origin/insertion

1.72

1.23

$35.7547

$61.50

$43.98

20552

Inj trigger point 1/2 muscl

1.56

1.08

$35.7547

$55.78

$38.62

20553

Inject trigger points 3/>

1.81

1.23

$35.7547

$64.72

$43.98

76942

US Guidance for Injection

1.70

$35.7547

$60.78

76881

US Extr non-vasc complete

3.29

$35.7547

$117.63

76882

US Extr non-vasc lmtd

1.02

$35.7547

$36.47

98925

OMT 1-2 regions

0.88

0.67

$35.7547

$31.46

$23.96

98926

OMT 3-4 regions

1.28

1.01

$35.7547

$45.77

$36.11

98927

OMT 5-6 regions

1.67

1.34

$35.7547

$59.71

$47.91

98928

OMT 7-8 regions

2.05

1.69

$35.7547

$73.30

$60.43

98929

OMT 9-10 regions

2.45

2.03

$35.7547

$87.60

$72.58

20600

Drain/inj joint/bursa w/o us

1.35

1.02

$35.7547

$48.27

$36.47

20604

Drain/inj joint/bursa w/us

2.05

1.32

$35.7547

$73.30

$47.20

20605

1.41

1.06

$35.7547

$50.41

$37.90

20606

Drain/inj joint/bursa w/us

2.27

1.51

$35.7547

$81.16

$53.99

20610

1.71

1.32

$35.7547

$61.14

$47.20

20611

Drain/inj joint/bursa w/us

2.62

1.78

$35.7547

$93.68

$63.64

(41)

Worth of Covered Service

•

New Patient/Consult

Example

New Patient with Diagnostic US and US

Guided Diagnostic Injections with OMT

99204-25

New Pt E&M

$165.90

76881

US Extr non-vasc complete

$117.63

20550-59

$60.07

20551

$61.50

76942

US Guidance for Injection

$60.78

98928

OMT 7-8 Areas

$60.43

(42)

Worth of Covered and Noncovered

•

Follow Up Visit for Reevaluation

99213-25

Established Patient Level 3

$72.94

76882

Limited US MSK Extremity

$36.47

98928

OMT 7-8 Areas

$60.43

F/U Subotal:

$152.61

PLUS Prolo:

$250.00

(43)

Worth of Covered

•

Follow Up without Prolotherapy

99213-25

Established Patient Level 3

$72.94

76882

Limited US MSK Extremity

$36.47

98928

OMT 7-8 Areas

$60.43

20550-59

$60.07

20551

$61.50

76942

US Guidance for Injection

$60.78

(44)

Modifiers

•

-25 Significantly Separately Identifiable E&M

Service; same provider, same DOS in addition

to another service/procedure

•

-59 Distinct Procedural Service

(45)

-59 SubModifiers

•

January 1, 2015

•

XE: Separate

E

ncounter; therefore distinct

•

XP: Separate

P

ractitioner; therefore distinct

•

XS: Separate

S

tructure; therefore distinct

•

XU:

U

nusual, nonoverlapping

–

Distinct since it does not overlap usual components

of main service (-22) (Dx & Tx procedure)

•

SUSPENDED until further notice

(46)

Medicare Participation

•

National Provider Identifier (NPI)

•

Provider Enrollment Chain & Ownership System

•

855-I & 855-R (type of corporate entity?)

•

Participation Agreement (CMS 460)… Annually

•

EDI (MAC) & EFT (CMS 588)

•

ABN (GA Modifier)

•

File 2Q if able

•

Co-pay: 20% of PFS not charges

•

Accept Assignment… no mas

Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

(47)

Medicare

Non-

Participation

•

Your choice… don’t sign CMS-460

–

Open enrollment mid-Nov through 31-Dec

•

Assignment accepted case by case

•

5% reduction in PFS

–

95% if “accepting assignment”

•

Limiting Charge = 115% of 95% of PFS

Source:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

(48)

Medicare

Opt Out

•

BBA 1997 Afforded option

•

Opt out 30 days prior to end of any quarter

–

In writing to MAC… specific language

•

A.K.A., Private Contracting

–

Must have contracts… seek legal counsel

•

Allowed to order/refer for covered services

–

SSA Sections 1128, 1156, 1892

•

Emergency service exception

Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

Source: http://www.aafp.org/practice-management/regulatory/medicare.html

(49)

2015 Bundled

Joint Injection and Ultrasound Codes

(50)

"It is not the strongest of the

species that survives, nor the

most intelligent, but the ones

most responsive to change."

Charles Darwin

(1809-1892)

(51)

2015 OIG Report

•

Medicare payments for E/M services

increased by 50% from 2001 to 2014

•

Spending went from $22.7B to $35B/qtr

–

Expected to double by 2021

•

However, over $70B per annum for Part B

–

Reduced by $16B since 2012

CBO Feb 2014

Pew Research.org

Kaiser Foundation

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/downloads/sgr2015f.pdf

(52)

2015 OIG FOCI

•

Modifier 25 Under Scrutiny

•

New Patient Hospital CPT Codes (‘consult’)

•

Correct Coding Initiative (CCI Edits)

(53)

2015 OIG Foci

•

EMR Upcoding

•

‘Cloned Notes’

•

Proving ‘Medical Necessity’

(54)

Summary

•

You protect yourself and your family even if

you are employed

•

Know the rules

•

The ‘rules’ change

•

Stay up to date

•

Be methodical in your

business practices

(55)

Thank You!

“What you get by achieving your goals is not as

important as what you become by achieving

them.”

•

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

•

https://www.cms.gov/Medicare/CMS-

Forms/CMS-Forms/downloads/cms1490s-english-instructions-partb.pdf

:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/downloads/sgr2015f.pdf