1-26-2013 joy's derm long session

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Chicago Dermatological Society

January 26, 2013

Presented byJoy Newby, LPN, CPC, PCSNewby Consulting, Inc.5725 Park Plaza CourtIndianapolis, IN 46220p ,Voice: 317.573.3960Fax: 866-631-9310

E-mail: [email protected]

This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered. Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the manual are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.g , gAny five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes service descriptions, instructions, and/or guidelines are copyright 2012 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical Association.For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation. The American Medical Association assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication.

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Commercial payers Department of Justice (DOJ) Office of Inspector General (OIG) Zone Program Integrity Contractors (ZPIC) Medicare Administrative Contractors (MAC) Medicare Administrative Contractors (MAC) Comprehensive Error Rate Testing Contractor

(CERT) Medicare and Medicaid Recovery Audit Contractors

(RAC) Medicaid Integrity Contractors (MIC) Medicaid Payment Contractors

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CPT Codes, Descriptions, and Modifiers Copyright 2012

American Medical Association

Justice Department recovered $3 billion in False Claims Act Cases in fiscal year 2011 (10/1/2010 through 9/30/2011)

28% of the recoveries in the last 25 years were b d d Ob k ffobtained since President Obama took office

(January 20, 2009) – Press release dated 12/19/2011

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The Chairperson of the Ophthalmology Department of the Temple University School of Medicine and also served as the Assistant Dean for Medical Affairs caused thousands of false claims to be submitted to health care benefit programs with f l h t t li th $4 5 illi ffalse charges totaling more than $4.5 million for services rendered between 2002 and 2007 to patients whom he did not personally see or evaluate.


American Medical Association 6

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At his direction, staff employees in the Ophthalmology Department would stack patient charts outside his office door at the main campus of Temple University Hospital.◦ The patients had been seen by other physicians p y p y

in the office but he would make notations in the charts falsely indicating that he had personally seen and evaluated the patients, when, in fact, he was outside of Pennsylvania in other locations, including Las Vegas, Nevada, Sarasota, Florida and Indian Wells, California.



◦ He would sign the patient charts and would fill out fee slips for the services that he falsely claimed to have provided to the patients.



Monroe physician to pay $950,000 to settle government civil fraud allegations (2011)◦ OB-GYN physician in Monroe, NC◦ Investigators found Dr. Francis-Lane knowingly

billed Medicaid for more extensive services than h ll d d kshe actually provided, a practice known as

“upcoding.” ◦ Investigators also found that Dr. Francis-Lane

regularly billed Medicaid for unnecessary tests◦ Claims submitted over a seven-year period from

2003-2009

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Between 2002 and the end of September 2012 Medicare, Medicaid, and numerous private insurers “…it would have been impossible for any physician

to provide the medical treatment to that number of patients in a single day. “

November 29, 2007, February 20, 2008, and June 19, 2008

Provided services to 82, 85, and 92 patients, and the aggregate “typical” time component associated with the codes submitted for payment were 30 hours, 35 hours, and 40 hours, respectively.



The OIG will review evaluation and management (E/M) claims to identify trends in the coding of E/M services. ◦ Medicare paid $33.5 billion for E/M services in 2010,

representing 30 percent of all Medicare Part B payments.

◦ E/M services also represented 45 percent of the top 20 procedure codes billed to Medicare in 201020 procedure codes billed to Medicare in 2010

◦ Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide.

◦ E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.

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May 5, 2012, OIG issues the first in a series of reports discussing the utilization of evaluation and management (E/M) Services◦ Coding Trends of Medicare Evaluation and

Management ServicesManagement Services The number of E/M services billed increased by

13 percent Established patient office visits represented the

largest amount of Medicare payments for E/M services in 2010

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99213 was billed most often during the 10-year period

Shift in billing from the three lower level E/M codes to the two higher level codes.

Physicians increased their billing of the two highest level E/M codes (99214 and 99215) by 17 percent between 2001 and 2010

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Determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations

Reviewing multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments

Medicare contractors have noted an increased frequency of medical records with identical documentation across services.



CMS approved limited review, statistical sampling of evaluation and management claims to calculate and project incorrectly paid claims

Connelly, Inc. the Region C Recovery Audit Contractor, ◦ RAC Region C includes Alabama, Arkansas,

Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico, and the US Virgin Islands.



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Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code

It is not appropriate to bill a higher level of E/M service when a lower level of service is warranted

The volume of documentation should not be used to determine the level of service

Services billed should be individualized to the presenting problem(s) on the date in question.

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In order to maintain an accurate record, document during or shortly after rendering the service

Medicare requires a legible identity for services providedprovided



Services provided by other health care providers (nurses, NPs, PAs) as ancillary to the physician’s service should be signed by the nonphysician provider

If billing “incident to,” the nonphysician provider should note in the medical record that the physician was in the facility at the time the service was providedfacility at the time the service was provided

Signature stamps cannot be used Authorized representatives signing your name is not

acceptable



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Medicare requires the individual who ordered/provided services be clearly identified in the medical records. ◦ The signature for each entry must be legible and

should include the practitioner’s first and last name.

◦ For clarification purposes, Medicare recommends including the applicable credentials, e.g., PA, DO, or MD.

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Regardless of the type used, a signature serves three main purposes:

• Intent: an electronic signature is a symbol that signifies intent such as an approval of terms, confirmation that the signer reviewed and approved the content, or the signer authored the document and approves thesigner authored the document and approves the content.

• Identity: the signature identifies the person signing.• Integrity: a signature guards the integrity of the

document against repudiation (the signer claiming the entry is invalid) or alteration



Medicare Contractors will not review unsigned documents.◦ Acceptable Signatures: Handwritten Electronic Signatures

Physicians must follow acceptable standards for electronic signatures



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If the signature is illegible, MACs, ZPICs and CERT shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry

If the signature is missing from an order, MACs and CERT shall disregard the order during the review of theCERT shall disregard the order during the review of the claim (e.g., the reviewer will proceed as if the order was not received)

If the signature is missing from any other medical documentation (other than an order), MACs and CERT shall accept a signature attestation from the author of the medical record entry



Providers should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met

Beware of templates that overestimate decision-making. Understand the logic of templates and/or computer programs used for E/M service coding



Coverage defined by:

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment for only those services considered medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

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For a service to be considered medically necessary, it must be all of the following: ◦ Appropriate in duration and frequency ◦ Suitable for the patient’s medical needs ◦ Provided in accordance with accepted standards p

of medical practices ◦ Neither experimental nor investigational ◦ Performed by qualified personnel in appropriate

settings Just because Medicare covers a particular service

does not mean the service is medically necessary.

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Medical necessity of E/M services is generally expressed in two ways: ◦ frequency of services◦ intensity of services

Medicare's determination of medical necessity is yseparate from its determination that the E/M service was rendered as billed.

At audit, Medicare will deny or down code E/M services that, in its judgment, exceed the patient's documented needs.

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Identify all the presenting complaint(s) and/or reason(s) for the visit for which physician work occurred. ◦ Demonstrate clearly the history, physical and

extent of medical decision-making associated with each problem.

◦ Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent and risk to the patient) was affected by comorbidities or chronic problems listed.

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Effective January 1, 1992 Defined service for auditing purposes Codes are specific to place of service Selection of level of care based on medical

necessity not the volume of documentationy Documentation Guidelines◦ 1995◦ 1997

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The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are:◦ History ◦ Examination ◦ Medical decision making ◦ Counseling ◦ Coordination of care ◦ Nature of presenting problem ◦ Time

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Chief Complaint History Components◦ History of Present Illness (HPI)◦ Review of Systems (ROS)◦ Past, Family, Social History (PFSH), y, y ( )

Physical Examination Decision Making◦ Diagnosis and Management Options◦ Amount and Complexity of Data◦ Risk Assessment

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When Provided◦ Counseling◦ Coordination of care

Nature of the Presenting Problem

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A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of

ti blpresenting problems.

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Minimal -- A problem that may not require the presence of the physician, but the service is provided under the physician's supervision.

Self-limited or minor -- A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.

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Low severity -- A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.

Moderate severity -- A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.

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High severity -- A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

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99201 Usually, the presenting problem(s) are self limited or minor.99202 Usually, the presenting problem(s) are of low to moderate severity.99203 Usually, the presenting problem(s) are

of moderate severity.99204 Usually, the presenting problem(s) are

of moderate to high severity. 99205 Usually, the presenting problem(s) are

of moderate to high severity.

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99211 Usually, the presenting problem(s) are minimal.

99212 Usually, the presenting problem(s) are self limited or minor.

99213 Usually, the presenting problem(s) are of low to moderate severity.

99214 Usually, the presenting problem(s) are of moderate to high severity.

99215 Usually, the presenting problem(s) are of moderate to high severity.

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In the case where counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing f ilit ) ti i id d th k t llifacility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

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Examples of E/M codes that can be selected based on content or, when appropriate, based on time:◦ Office and other outpatient codes◦ Observation codes◦ Inpatient hospital codes◦ Nursing facility codes◦ Assisted living facility and home visit codes

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Documentation requirements◦ Total face-to-face or floor/unit time (in minutes)◦ Amount of time spent in counseling/coordination

f (i i )of care (in minutes)◦ Synopsis of the counseling/coordination of care

that took place

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History◦ 1995 - An extended HPI consists of four or more

elements of the HPI DG: The medical record should describe four or

more elements of the present illness (HPI) ormore elements of the present illness (HPI) or associated comorbidities

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History◦ 1997 - An extended HPI consists of at least four

elements of the HPI or the status of at least three chronic or inactive conditions. DG: The medical record should describe at least DG: The medical record should describe at least

four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.

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1995 – Exam based on body areas and organ systems

◦ Problem Focused -- a limited examination of the affected body area or organ system (one body area or organ system)

◦ Expanded Problem Focused -- a limited examinationExpanded Problem Focused a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (two to seven body areas or organ systems)

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Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s) – two to seven body areas or organ systems -difference is the detail in which the examined systems are described (CMS never formally adopted the “5-7 organ systems”)organ systems )

Comprehensive -- a general multi-system examination or complete examination of a single organ system ◦ The medical record for a general multi-system

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

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Level of Exam Perform and Document

Problem Focused One to five elements identified by a bullet.

Expanded ProblemFocused

At least six elements identified by a bullet.

Detailed At least twelve elements identified by a bullet.

ComprehensivePerform all elements identified by a bullet; document every element ineach shaded box and at least one element in each unshaded box.



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Same requirements for both the 1995 and 1997 guidelines

Must meet or exceed the code requirements for two of three elements◦ Number of diagnoses or management options◦ Number of diagnoses or management options◦ Amount of and/or complexity of data

ordered/reviewed◦ Highest risk strata for Presenting problem Diagnostic procedures/tests ordered Management option selected



Chief Complaint The chief complaint is a concise statement

describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

Not acceptable◦ Follow-up◦ Med Check◦ Wants to establish◦ 3-mo check up◦ Follow-up hospital

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Symptomatic patients◦ Obtain 4 HPI elements Location Quality SeveritySeverity Duration Timing Context Modifying Factors Associated Signs and Symptoms

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Document an ROS for the system(s) related to the presenting problem. ◦ Record positives and pertinent negatives. Never note the system(s) related to the

presenting problem as "negative"presenting problem as negative . Use notations such as "normal" or "negative"

only for systems not related to the presenting problem.

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◦ Don't record unnecessary information solely to meet requirements of a high level service when the nature of the visit dictates a lower level service to have been medically appropriate.

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Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. ◦ Don't use the term "non-contributory".◦ Record information about all three realms to

document "complete" PFSH for the following services: new patient or initial services in office and inpatient hospital, observation, domiciliary, and home, as well as consultations and comprehensive Nursing Facility (NF) assessments.

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◦ As with the information recorded in the ROS, don't record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates a lower-level service was medically appropriate.

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System/Body Area Elements of Examination

Constitutional

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

i f j i d lidEyes • Inspection of conjunctivae and lids

Ears, Nose, Mouth, and Throat

• Inspection of lips, teeth and gums• Examination of oropharynx (eg, oral mucosa, hard and soft

palates, tongue, tonsils, posterior pharynx)Neck • Examination of thyroid (eg, enlargement, tenderness, mass)

Cardiovascular• Examination of peripheral vascular system by observation (eg,

swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

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Skin • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (whenindicated) and extremities

• Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers,susceptibility to and presence of photo damage) in eight of the following ten areas: Head including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back Right upper extremity Left upper extremity Right lower extremity Left lower extremity

NOTE: For the comprehensive level, the examination of at least eight anatomic areas must beperformed and documented. For the three lower levels of examination, each body area iscounted separately. For example, inspection and/or palpation of the skin and subcutaneoustissues of the right upper extremity and the left upper extremity constitutes two elements.

• Inspection of eccrine and apocrine glands of skin and subcutaneous tissue withidentification and location of any hyperhidrosis, chromhidroses or bromhidrosis



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Gastrointestinal • Examination of liver and spleen• Examination of anus for condyloma and other lesions

Lymphatic • Palpation of lymph nodes in neck, axillae, groin and/or otherlocation

Extremities • Inspection and palpation of digits and nails (eg, clubbing,cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Neurological/ • Brief assessment of mental status includingPsychiatric Orientation to time, place and person

Mood and affect (eg, depression, anxiety, agitation)



Always examine the system(s) related to the presenting problem and do not describe it as "normal" or "negative." Use "Normal," "negative" and "WNL" notations only to describe unaffected or asymptomatic organ systems.

Code the physical examination considering the clinical circumstances of the encounter.

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Assessment◦ Problems identified in the chief complaint and HPI must be

addressed in the assessment and plan.◦ Diagnosis codes marked on the superbill must be

supported by the documentation in the assessment.◦ Diagnoses listed in the assessment must be pertinent to the

specific encounter and should have a documented plan or identify co-morbidity for presenting problem.

Plan◦ Document diagnostic tests being ordered◦ Patient instructions◦ When patient is to return to the office/clinic

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Record relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which Evaluation and Management (E/M) is clearly g ydemonstrated in the record of the other key components.

Document all diagnostic tests ordered, reviewed and independently visualized as part of the work of the encounter.

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Office or other outpatient visit for the evaluation and management of an established patient who may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing these

iservices. For Medicare purposes, the physician must provide

“direct supervision” (be physically present in the office suite when ancillary staff evaluates and/or treats the patient, and be immediately available to communicate with and direct the staff).

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Established E/M office/other outpatient◦ 99214

Subsequent inpatient hospital E/M◦ 99233

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99214 requires 2/3◦ detailed history◦ detailed exam◦ moderate complexity medical decision making

Documentation supports recode from 99214 to 99213◦ expanded problem focused history◦ no exam ◦ low complexity medical decision making

Visit was not of moderate to high severity

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The goal of Medicare is to "pay claims right the first time." Both upcoding and under coding are viewed as errors by Medicare.

If your billing pattern significantly varies from h f l d dthat of your peers, please review your coding and

billing of this category of E/M services for accuracy.

If error rates do not decrease, WPS Medicare may have to perform additional edits/audits or provider specific reviews to lower the error rate.



Comparative Billing Reports reveal utilization patterns and provide comparative data on how one individual health care provider varies from other providers within their state and across the nationacross the nation

Can be issued by◦ Local Medicare Administrative Contractor◦ CMS) awarded the national Comparative Billing

Report (CBR) contract to SafeGuard Services LLC (SGS)



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CMS expects that the CBR will accurately reflect a provider’s performance versus his or her peers

CMS also expects the provider to use the information to identify opportunities forinformation to identify opportunities for improvement



No specific data has been published for dermatology on WPS’ websites for its Legacy Contract or for the J5 and J8 contractsTh t lid id ti l d t f E/M The next slide provides national data for E/M utilization for dermatologists between 1/1/2011 and 6/30/2011◦ Totals do not add to 100% due to rounding



E/M CPT Code

National Utilization

99201 6.98%



99202 45.14%99203 44.53%99204 3.13%99205 0.21%

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E/M CPT Code

National Utilization

99211



99212 29.80%99213 59.67%99214 10.29%99215 0.23%

Payment for minor surgical procedures includes payment for certain E/M services that are necessary prior to a procedure being performed.◦ It may be necessary to indicate that on the day a◦ It may be necessary to indicate that on the day a

procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.

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Definition◦ Significant, Separately Identifiable Evaluation and

Management Service by the Same Physician on the Same Day of the Procedure or Other Service y

When a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier -25 should be appended to the visit code.

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Georgia Cancer Specialists, PC agreed to pay $4.1 million to settle claims that it violated the False Claims Act by billing Medicare for evaluation and management services that were not permitted by Medicare rules. ◦ Georgia Cancer Specialists is one of the largest

private oncology practices in the country with 27 offices located throughout the Atlanta metro area.

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The settlement announced resolves allegations related to the billing for E/M services on the same day as a related procedure

U.S. Attorney’s Office alleged that Georgia Cancer Specialists applied modifier -25 to claims that did p ppnot qualify for its use, leading to overpayments by Medicare

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An investigation into the billing patterns of a major healthcare facility in Ohio revealed modifier -25 was being appended to outpatient clinic visits when there was no documentation in the medical records to support that a significant, separately identifiable E/M service was performed.

◦ The overpayment dollar amount for this facility was over $500,000.

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All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.◦ Modifier 25 indicates that on the day of a y

procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the procedure or service performed.

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Inappropriate Usage◦ Documentation shows the amount of work

performed is consistent with that normally performed with the procedure.

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Medicare will not pay for a separate E/M service on the same day as a dermatologic service unless a documented significant and separately identifiable medical service is rendered.

The service must be fully and clearly documented in the patient's medical record and a modifier 25 should be used.

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The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.

However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

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The E/M service and minor surgical procedure do not require different diagnoses.

If a minor surgical procedure is performed on a new patient, the same rules for reporting E/Mnew patient, the same rules for reporting E/M services apply.◦ The fact that the patient is “new” to the provider

is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure.

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If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E/M service is not separately reportable.

However, if the physician also performs a medically reasonable and necessary full neurological examination, an E/M service may be separately reportable.

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The Government Accountability Office awarded the J6 contract (IL, WI, MN) to National Government Services

Will transition during 2013 Will transition during 2013 NGS’ includes the following example of when an

E/M code with modifier -25 appended can be billed on the same date of service as a lesion removal



A patient sees a dermatologist for a lesion on his leg. During the exam, the patient mentions a rash on his arm. The symptoms have been worsening so that the patient has been unable to sleep at night p p gdue to the itching. The lesion on the leg is removed and the provider writes a prescription for the rash. ◦ In this case the rash is considered to be a

separate and significant service.



Modifier -25 is not used to report an E/M service that resulted in a decision to perform surgery. ◦ The -57 modifier is not used with minor surgeries

because the global period for minor surgeries does not include the day prior to the surgery. M h th d i i t f th i◦ Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit is not billed in addition to the procedure.

Carriers should not pay for an evaluation and management service billed with the CPT modifier -57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.

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Modifier 57 AMA Definition◦ Decision for Surgery: An evaluation and management

service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M serviceto the appropriate level of E/M service.

Modifier -57 CMS Definition◦ Carriers pay for an evaluation and management

service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service resulted in the decision to perform the procedure.

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Evaluation and Management Services—Use of Modifiers During the Global Surgery Period◦ Reviewing the appropriateness of the use of certain

claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were inwith modifiers used during such a period were in accordance with Medicare requirements.

◦ Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period.



Required for all procedures including those performed in the office setting (CPT codes 10040 – 69999)

Recommended components◦ Reason for performing the procedure◦ Consent◦ Description of lesion (including size, number, location, etc.)◦ Prep◦ Type and amount of anesthesia (if appropriate)◦ Description of the procedure including instruments used,

technique, sutures, etc.◦ Bandage◦ Completed with/without complication◦ How patient tolerated the procedure◦ Postop instructions given to the patient◦ Pre and postoperative diagnoses



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The HCPCS/CPT codes for lesion removal include the procurement of tissue from the same lesion by biopsy at the same patient encounter. CPT codes 11100-11101 (biopsy of skin, subcutaneous tissue and/or mucous membrane) should not be reported separately. ◦ CPT codes 11100-11101 may be separately

reportable with lesion removal HCPCS/CPT codes if the biopsy is performed on a different lesion than the removal procedure.



Lesion removal may require closure (simple, intermediate, or complex), adjacent tissue transfer, or grafts. If the lesion removal requires dressings, strip

closure or simple closure these services areclosure, or simple closure, these services are not separately reportable. Thus, CPT codes 12001-12021 (simple repairs) are integral to the lesion removal codes.



Intermediate or complex repairs, adjacent tissue transfer, and grafts may be separately reportable if medically reasonable and necessary.

However excision of benign lesions with◦ However, excision of benign lesions with excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which should not be reported separately.



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A single physician performs both the surgery and pathologic examination of the specimen(s). The Mohs micrographic surgery CPT codes include skin biopsy and excision services (CPT codes 11100-11101 11600-services (CPT codes 11100 11101, 1160011646, and 17260-17286) and pathology services (88300-88309, 88329-88332). Reporting these latter codes in addition to the Mohs micrographic surgery CPT codes is inappropriate.



However, if a suspected skin cancer is biopsied for pathologic diagnosis prior to proceeding to Mohs micrographic surgery, the biopsy (CPT codes 11100-11101) and frozen section pathology (CPT code 88331) may be reported separately utilizing modifier 59 or 58 to distinguish the diagnostic biopsy from the definitive Mohs surgery.



Includes indications for coverage that must be documented in the patient’s medical record when the decision for removal is made

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. ◦ The physician has the responsibility to notify the patient in

advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment.

◦ Charges should be clearly stated as well.◦ Diagnosis Code V50.1 should be used for all cosmetic

procedures



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A medical record statement of "irritated skin lesion" is insufficient justification for lesion removal when solely used to reference a patient's complaint or a physician's physical findings. p y p y g

Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient's symptoms and physical findings



Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performedperformed.

Each benign lesion excised should be reported separately.



Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). h f h d The margins refer to the narrowest margin required to

adequately excise the lesion, based on the physician's judgment.

The measurement of lesion plus margin is made prior to excision.◦ Measurement must be documented in the surgical

procedure note



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Physicians who do not successfully report PQRS Measures in 2013◦ a minimum of 3 measures at least 50% when applicable for claims-based reporting 80% when applicable for registry reportingpp g y p g

OR◦ One measures group for at least 20 patients

2015 Medicare payments will be reduced by 1.5%



Current implementation date – October 1, 2014 Prepare for higher level of specificity◦ ICD-9 ~ 14,000+ codes 3-5 numeric (+ V and E-codes)3 5 numeric (+ V and E codes)◦ ICD-10 ~ 72,000 3-7 alphanumeric codes

It is not just about coding – It is about clinical documentation of records to support accurate coding



ICD-10-PCS allows identification of: ◦ Body system ◦ Root operation ◦ Body part ◦ Approach pp◦ Device involved in the procedure ◦ Structural Differences



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New for physicians and coders ◦ Laterality – need to know which side was affected ◦ Encounter – need to know if it was an initial

encounter, subsequent encounter or sequela A i i d k h h i d i◦ Activity – need to know what the patient was doing when the injury occurred ◦ Place of Occurrence – need to know where the

patient was when the injury occurred



Not always a one-to-one match between ICD-9 and ICD-10 codes: ◦ Multiple ICD-10 codes equate to one ICD-9 code ◦ Multiple ICD-9 codes equate to one ICD-10 code

General Equivalent Mapping (GEM) Structural Differences



Planning Phase Assign overall responsibility and decision-

making authority for managing the transition Ensure top leadership understands the breadth

d i ifi f h ICD 10 hand significance of the ICD-10 change Plan a comprehensive and realistic budget Ensure involvement and commitment of all

internal and external stakeholders Adhere to a well-defined timeline



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Preparing for Documentation Changes and Improvements Inventory Systems and Identify Discrepancies Evaluate Current Software Systems Train and Educate Staff Test the Documentation Process


American Medical Association100

Available on CMS website at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

CMS has developed implementation handbooks to assist with the transition from ICD-9 to ICD-to assist with the transition from ICD 9 to ICD10 codes.

Each guide provides detailed information for planning and executing the ICD-10 transition.

Use the guides as a reference whether you're in the midst of the transition or just beginning.



The appendix of each handbook has templates that are available for download in both Excel and PDF files.

The templates are customizable and have been created to help entities clarify staff roles, set internal deadlines/responsibilities and assess vendor readinessdeadlines/responsibilities and assess vendor readiness.

View the tailored step-by-step plans and relevant templates for each of the following audiences impacted by the transition:◦ Large Practices ◦ Small/Medium Provider Practices



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Timelines To help you with your transition, download the CMS

timeline widget or view the printer-friendly versions of the large practice and small practice implementation timelines.◦ Please note the widget and timelines can be used to

l l h l f C 0calculate how long specific ICD-10 transition activities will take.

◦ The handbooks provide detailed information on transition activities for providers.

◦ Dates in the widget, timelines, and handbooks are based on an October 1, 2013, deadline, which HHS extended to October 1, 2014.



Questions?

Th k f i i i !Thanks for inviting me!

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1-26-2013 joy's derm long session

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