Coding and Billing for Internists’ Services

Challenges and Opportunities

June 2010

Foundation on which Billing and Coding is Based

AMA maintains CPT book of codes that describe physician services

CMS supplements the CPT book as needed

RBRVS, managed by CMS, determines payment for each physician service

Each service has a relative value for each of three main components—work, practice expense, and professional liability insurance, with each being adjusted to reflect geographic input price differences

Medicare multiplies total, adjusted relative value for each service by a dollar multiplier, or conversion factor

Medicaid, other government, and private payers generally use RBRVS as basis for payments

Medicare Payment Uncertainty

Medicare annual payment updates lag behind medical inflation

Flawed sustainable growth rate formula regularly calls for unsustainable cuts in Medicare physician payments

Congress typically acts to replace an impending cut with a freeze or small increase around time it is to take effect

Congress almost certainly will act to avoid large cut but is avoiding a complete long-term fix because it’s costly

ACP participating in this messy process to represent the interest of its members

Focus on What You Control General coding and billing guidance

• Do what is medically necessary

• Document what you did according to guidelines

• Use up-to-date CPT and diagnosis codes

• Investigate payment denials

• Conduct periodic self audits

• Engage in continual coding and billing education

Understanding coding and billing rules is vital to health of practice

Coding and Billing Challenges and Opportunities

Challenge: “Welcome to Medicare” Exam Benefit

Changes in 2009 resulting from 2008 law implementation:

• Patients now eligible 12 months after enrollment, instead of 6 months

• No longer required to perform EKG, but must advise/refer as needed

• Now required to conduct BMI and discuss advance directive

• Use new HCPCS G0402, instead of old G0344

Can bill medically necessary E/M on same date as appropriate—use modifier -25

ACP has contended pay too low; CMS increased pay for service for 2010 to $154, up from $92

CMS working to establish details of an annual wellness visit/preventive care plan benefit for 2011 as required by March 2010 federal health reform law

Challenge: Billing for Consultations

Requirements for a billing a CPT consultation service code:

• Furnished at the request of another physician seeking opinion or advice

• Must make a treatment option(s) decision/recommendation

• Must provide opinion or advice in a written report back to the requesting physician

Consulting physician can initiate treatment, e.g., diagnostic or therapeutic tests or procedures, during consultation visit

On-going care furnished by the consultant after initially providing opinion or advice is billed using office, subsequent hospital, nursing facility visit codes

Dramatic Medicare Consult Policy Change CMS no longer recognizes CPT consult

codes for Medicare payment purposes beginning in 2010

CMS rationale for change:

• Agency long-expressed concern that physicians did not bill consults correctly

• Reviews determined that Medicare overpaid as many consults billed were not supported by documentation

• Agency believes consult service work is “clinically similar” to office, hospital, NF visits

Dramatic Medicare Consult Policy Change

Consults to be billed using CPT codes for:

• Office visits, 99201-99215

• Initial hospital care (admit). 99221-99223

• Initial NF care, 99304-99306

Change was unexpected and has far-reaching implications

ACP position on Medicare consult payment policy is at http://www.acponline.org/running_practice/practice_management/payment_coding/medicare/changes2010/feeschedule.htm#advocacy

Documentation Implications of Consult Change Documentation rules for “replacement” codes

apply based on code used, thus:

• No requirement that the requesting and consulting physician document request in medical record

• Consultant not required to send a written report with opinion /advice back to requesting physician

• No need for auditors to distinguish a request for a consult from a referral that constitutes a transfer of care

Admitting physician bills initial hospital care code with a “AI” modifier to distinguish service from consultant(s)

Payment Implications of Consult Change

To redistribute the money that Medicare paid for the no-longer-recognized CPT consult codes:

• Payment for each office visit increased about 3%

• Payment for initial hospital and initial NF care services increased about 1%

In general, payments for consult services will be lower as a result of use of CMS-required replacement codes

Payment Implications of Consult Change

Consult Code

2009 Payment

Replacement Code

2010 Payment

99241 $48.69 99201 $38.96

99242 $90.90 99202 $67.45

99423 $124.80 99203 $97.75

99244 $184.32 99204 $151.49

99245 $226.52 99205 $190.45

Payment Implications of Consult Change

Consult Code

2009 Payment

Replacement Code

2010 Payment

99251 $48.69

99252 $75.75

99253 $114.70 99221 $94.14

99254 $165.56 99222 $127.33

99255 $201.99 99223 $186.84

Payment Implications of Consult Change No clear guidance on how to bill low-level

hospital consults as no initial hospital code match for 99251-99252

Consults furnished to established outpatients, 99211-99215, experience biggest payment hit

• Consult for pre-op clearance on known beneficiary dictates billing established patient office visit

Physicians who do a significant number of consults will see overall revenue decline; those who do few see revenue rise

Confusion when a secondary payer is involved

Payment Implications of Consult Change Can bill prolonged service code in addition

to an office or hospital visit code (as appropriate and if documented)

Consult can be billed as critical care service if it meets the CPT definition of critical care

Coordination of care could suffer if consultants feel less compelled to send a written report to requesting physician

Most private payers initially decided to continue to pay the CPT consult codes but more are adopting the Medicare policy

Tips for Billing Private Payers Consults

Consultants can receive higher payments from private payers still recognizing CPT consult codes

Consult can be furnished by a physician in the same group as the requesting physician—consultant is expected to practice a different specialty but exceptions are made for same-specialty expertise

The service resulting from a surgeon’s request to clear a patient as being fit for surgery can be billed as a consultation for major procedures

Check if private payer follows the old Medicare rule that allows billing a consult for patient-initiated second opinions before major surgery or test

Challenge:Medicare Teaching Physician

Regulations Medicare pays teaching/attending

physician for services furnished involving a resident when:

• Services performed by teaching physician—duplicates resident service

• Services performed by teaching physician jointly with resident

• Services performed solely by resident under Primary Care Exemption

For first two scenarios, teaching physician must personally see the patient, perform the critical/key portion of the service, and participate in the management

Teaching Physician Regulations

Teaching physician must tether/link note to resident’s note

Billing is based on the combination of the teaching physician’s and resident’s documentation

Examples of acceptable documentation:• I saw and evaluated the patient. Discussed /w resident

and agree w/resident’s findings and plan as documented in the resident’s note.

• See resident’s note for details. I saw and evaluated the pt and agree with the resident’s findings and plan as written.

Examples demonstrate saw patient, performed key portion, and participated in management

Teaching Physician Regulations

Examples of unacceptable documentation:• “Agree with the above.”

• “Rounded, reviewed, agree.”

• “Discussed with resident. Agree.”

• Signature alone

Other documentation tips:• There is no royal “we”; use “I” to demonstrate

involvement

• Can use template/macro, such as through EHR, but must sufficiently modify to reflect specific encounter/scenario

Suggested Teaching Physician Documentation

I saw and evaluated the patient and reviewed (Resident’s Name) notes. I agree with the history, physician exam and medical decision making with the following additions/exceptions/observations : ____________________________________________________________________________________________________________________________________________________________________________________

Attending’s SignatureDate

Teaching Physician Primary Care Exception

Teaching physicians can be paid for certain services furnished solely by a resident when they are provided in outpatient facilities for which resident time is counted toward the direct GME payment to the facility

Teaching physician can only be paid for resident low-level outpatient E/M visit services, 99201-99203 and 99211-99213

Resident must have completed at least six months of training program

Teaching physician cannot supervise more than four residents and must be immediately available to assist

Challenge: Billing for “Incident-to” Services

Medicare allows physicians to bill for outpatient services performed by personnel that are “incidental” but integral and be paid as if the physician performed the service

Incident to rules enable physician to bill 99211 when service furnished by office staff

• This minimal service can be performed by any clinical staff member, e.g., medical assistant, RN, PA

More complicated incident-to rules pertain to billing of 99212-99215

• Service must be performed by CMS designated clinical staff PA, NP, CNS

Billing for “Incident-to” Services Conditions must be met to bill for higher-level PA,

NP, CNS services• Physician must perform the initial visit and

establish the care plan for patient/condition

• Physician must provide direct supervision, defined as in the office suite but not necessarily in the same exam room, and be immediately available to assist

Medicare pays 100% of its normal physician fee schedule amount

PA, NP, CNS can provide services that fail to meet the incident-to rules

• The practitioner furnishing the service must be listed on the claim/bill

• Medicare pays the practice 85% of its normal fee schedule amount

Challenge: Billing Anticoagulation Management Services

Medicare payment policy makes it challenging to be adequately paid for managing patients receiving long-term, outpatient anticoagulant drug, i.e., warfarin therapy

ACP helped establish new CPT codes in 2007 to provide a more rationale way for physicians to bill and be paid for anticoagulation management services • A code to report an initial 90-day period that

involves at least 8 INRs, CPT 99363

• A code to report each subsequent 90-day period that involves at least 3 INRs, CPT 99364

Codes encompass physician review and interpretation of each INR, patient instructions, dosage adjustments, and ordering additional tests

Billing Anticoagulation Management Services CMS refuses to pay for these new CPT codes,

which would generally increase amount Medicare pays physician

The agency retained its policy that the practice can bill a 99211 when office personnel has a face-to-face encounter with the patient, higher level when physician has direct contact

ACP is concerned that some Medicare contractors may prohibit billing 99211 unless there is a change in drug regimen, treatment plan• This compounds the problem by making an

inadequate billing policy more restrictive

Check with private insurers to see if they pay for CPT 99363 and 99364

Opportunity: E/M Counseling Exception

Have option to select an E/M level of service based on time when counseling and/or coordination of care accounts for more than 50% of physician face-to-face time with patient

Compare total physician time for encounter to CPT “typical time”

Not subject to 1995 or 1997 E/M documentation guidelines

Documentation should note amount of time counseling and what was discussed (must be medically necessary)

List counseling time as fraction of total, e.g. “ccc 15/25” in addition to describing pertinent issues discussed

Opportunity: Home Health Care Plan Certification/Re-

certification Bill HCPC G0180 for certification of the initial

home health care plan • Medicare pays $58

Bill HCPCS G0179 for re-certification of care plan • Use if patient has received home health services within

past 60 days

• Medicare pays $44

Document thought-process in agreeing with plan and/or in changing to better meet patient’s needs

Keep copy of approved care plan in record or be able to access it if needed

CMS goal is incentive to physician to carefully review home health agency care plans to ensure appropriate utilization

Opportunity: Smoking Cessation Counseling

Medicare covers for:

• Patients with disease caused or exacerbated by tobacco use; or

• Patients taking medications complicated by tobacco use

Covers 2 attempts to quit per year

Each attempt can involve up to 4 counseling sessions

Bill CPT 99406 for 3-10 minutes of counseling

• Pays $13

Bill CPT 99407 for >10 minutes of counseling

• Pays $25

Append modifier -25 to office visit (or other service) done on same date

Opportunity: Screening Pelvic/Breast Exam

G0101 - cervical or vaginal cancer screening; pelvic and clinical breast examination

Medicare covers annually for women at high risk or of childbearing age with abnormal Pap in last three years, and every two years for all other female beneficiaries

Pays $35

Can bill in addition to other same-visit/date services: • Obtaining a smear for screening Pap test Q0091—pays

$40

• Acute/chronic “medically necessary” service, e.g., 99213

• Medicare non covered comprehensive preventive billed to patient, e.g., 99397

Opportunity: Use CPT Modifiers as Appropriate

Modifier -25 – significant, separately identifiable E/M service furnished by the same physician on the same date as procedure or other service

Can be used to bill an E/M service on the same date as a minor procedure, e.g., joint injection

Can be used to bill an E/M service on the same date as a number of Medicare-covered preventive services, e.g., Medicare-covered screening pelvic/breast exam, HCPCS G0101

Can be used to bill an E/M service on the same date as another E/M service in limited circumstances, e.g., critical care service in addition to initial hospital if patient crashes

Opportunity:When a Patient is “New” Again

You can bill a “new patient” service when neither you or a physician of the same specialty in your group practice have furnished a face-to-face professional service within the past three years• Patient you provided a flex sig two years ago, not

a new patient

• Patient for whom you read an x-ray two years ago (without seeing the patient) is a new patient

Pay attention when providing office visits, new patient visits receive higher payment • 99204 – pays $151

• 99214 – pays $98

Opportunity: Non-covered Medicare Services That

Can Be Billed to Patients Telephone services

• 99441 - 5-10 min. medical discussion

• 99442 – 11-20 min. medical discussion

• 99443 – 21 -30 min. medical discussion

• Must be initiated by established patient call to physician

• Cannot be billed if face-to-face service results within 24 hours or if related to face-to-face service provided within past 7 days

E-service

• 99444 – on-line service to established patient

• Physician’s personal, timely response to patient inquiry that involves permanent storage of documentation pertaining to exchange

Non-covered Medicare Services that Can be Billed to Patients

E-service (cont.)

• Can only be reported once during same episode of care over 7 days

• Not related to face-to-face E/M service within past 7 days

Preventive Medicine Services, e.g. 99397 – periodic comprehensive preventive medicine evaluation, established patient, 65 years and older

Medicare considers above services to be “non covered,” meaning that physician can bill patient his/her usual charge

Not necessary to have patient sign an ABN form but good idea to discuss situation with patients in advance of billing them

Opportunity:Medicare Bonus Payment – PQRI

Medicare pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI)

Report on how care furnished compares to evidence-based clinical guidelines for a variety of medical conditions, e.g. diabetes, heart disease

Earn a 2% bonus for 2010 for reporting on how care provided aligns with quality measures, selecting from a variety of reporting methods

ACP resources available at http://www.acponline.org/running_practice/practice_management/payment_coding/pqri.htm

Opportunity:Medicare Bonus Payment – E-Rx

Earn a 2% bonus for 2010 for reporting e-prescribing events using a qualified e-prescribing system

List code G8553 on claim form to indicate an e-prescribing event associated with eligible encounters, primarily office visits

Receive bonus if correctly report code a minimum of 25 times in 2010

Other reporting options, e.g., through an EHR, are available

ACP resources available at http://www.acponline.org/running_practice/technology/eprescribing/medicare_program.htm

ACP Contacts for Questions/Comments Regulatory and Insurer Affairs

Department

• Brett Baker - bbaker@acponline.org

• Debra Lansey - dlansey@acponline.org

• Tenita Richards - trichards@acponline.org

Center for Practice Improvement and Innovation

• Margo Williams - mwilliams@acponline.org