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Moneyball: CPT Coding Analysis

Betsy Nicoletti, MS, CPC

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

©2017 Betsy Nicoletti

Betsy, Nicoletti, MS, CPCFounder, CodingIntel.com; Consultant, Medical Practice Consulting, LLC, Northampton, Massachusetts

Nicoletti is a speaker, writer, and consultant with expertise in primary care coding/compliance and Medicare regulations for family medicine practices. In addition to being an experienced auditor, she is an expert on evaluation and management (E/M) notes created by electronic medical record (EMR) systems. Having worked in and around physician offices for more than 25 years, she has had more than 2,500 meetings with health care providers and reviewed more than 40,000 medical notes. Her fast-paced, engaging coding education sessions help health care providers improve their coding accuracy and clarity. Nicoletti is the author of The Field Guide to Physician Coding and Auditing Physician Services. In addition, she blogs at www.nicolettinotes.com and is a contributor to Family Practice Management. She earned a Master of Science in Organization and Management degree from Antioch University New England, Keene, New Hampshire, and she is a member of the National Speakers Association and the Medical Group Management Association (MGMA).

Learning Objectives

1. Explain the latest updates to billing and coding procedures.

2. Identify techniques to improve coding and billing practices.

3. Determine areas of opportunity for maximizing revenue.

Associated Sessions

• Moneyball CPT Coding Analysis: Ask the Expert

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Audience Engagement SystemStep 1 Step 2 Step 3

Agenda

• Coding analysis without pulling a single chart– CPT and risk adjusted diagnosis coding

• Coding updates

• Process improvement suggestions for selected services

Why are my RVUs so different: one practice’s analysis

• E/M measure to track for established patient visits

• Frequency/variance of reporting high RVU valued services

• Compliance issues based solely on CPT report

• Diagnosis coding prior to ICD-10 implementation—didn’t support risk adjustment

CMS norms—established patients

FP E/M established patients

CMS data

Single metric

• One predictor of revenue and wRVU• Significant variation from CMS norm by

provider, by practice sites• Confounded by incorrectly assigning

nurse visits in a practice

99214s as a percentage of total established patient visits

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Inaccurately assigned nurse visits confounds % of 99214 metric

FP 18 CMS

99211 33% 3.85%

99214 32% 45%

Ratio of 99213‐99214

0.96 0.99

99214 As Percent of Established Patients

High Coders

Low Coders

Ratio of 99213 to 99214

Many clinicians with more 99213s than the CMS norm

Practice two

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent 99214 of Established Patient Visits

Potential For Lost Revenue

Potential For Overbilling

MedicareAverage

Practice two

-

0.50

1.00

1.50

2.00

2.50Ratio of 99213s to 99214s

Potential

Potential For Overbilling

MedicareAverage

3rd metric: wRVU per encouterMGMA Family Practice: wRVUs 4904, Encounters 3519 = 1.39 wRVUs/encounter

Causes of variation in this metric:• Level of service• High RVU valued services wellness visits

transitional care management and split visits

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RVU variation

• Can be attributed to E/M frequency or percentage of new patient visits

• Often variance is related to performing high RVU valued services such as TCM

• Wellness visits

• Wellness visits with problem oriented visits

Transitional Care Management (TCM)

Comparing established patient visits with TCM

wRVUTotal non‐

facility RVUs

TCM ‐ 99495 2.11 4.6399214 1.5 3.03

TCM ‐ 99496 3.05 6.699215 2.11 4.09

TCM by Family Practice Sites Revenue Opportunity: TCM• Assume 120 TCM visits and 120 fewer 99214s• $6,800 Revenue Opportunity per Provider

TCM

• If not billing, most physicians and NPPs are doing the post discharge work

• This is an easy revenue pick up

Wellness visitswRVU

Total non‐facility RVUs

Welcome to Medicare  2.43 4.7

Initial Annual Wellness  2.43 4.85

Subsequent Annual Wellness

1.5 3.28

99214 1.5 3.03

99215 2.11 4.09

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Wellness Visits by Family Practice Site Revenue Opportunity: Wellness Visits

• $13,000 Revenue Opportunity per Provider

• Assume 300 Wellness visits and 300 fewer 99214s—CONSERVATIVE assumption. Many providers do both at one visit.

Why is $13,000 conservative?• Wellness and problem oriented visit may be performed on

the same day

• Often both are documented

• Providers: all or nothing

You don’t have to pull a single chart

Compliance issues• Nurse visits in some practices “assigned” to one

provider

• Nurse visits are incident to services, and should be reported by supervising clinician (physician or NPP)

• High volume 99212s—incorrectly reporting E/M with every procedure

• New patient visits: many providers had a favorite—all billed at this level

• Two providers reported all TCM services at the highest level

Compliance issues

This is a revenue or compliance issue

Volume usually small

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Revenue issues

PTINR and finger stick billed:

Finger stick billed with no lab test

Nebulizer treatment with no medications

Vaccines/injections billed with no administration code

Finger stick always bundled!

Risk adjusted diagnosis coding• Fee-for-service: Individual claims paid based on

fees related to CPT code

• Contract with “risk adjustment” include increased payment based on acuity of patient population, utilization, quality measures and patient satisfaction

• Diagnosis coding describes the acuity of a patient and a panel of patients

ICD‐10 Guidelines

Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment. 

Do not code conditions which no longer exist.

Conditions that affect patient care

• Discussion of symptoms or status in HPI

• Reviewing diagnostic tests related to a problem

• Managing the problem (treatment, discussion)

• Consideration of problem discussed in assessment

Diagnosis coding• Report chronic conditions that are treated/addressed once

per year

• For chronic conditions, avoid “unspecified” if there is a manifestation or complication

• Apply status codes, such as long term use of insulin, BMI ≥ 40, HIV status, non-traumatic amputation of toe or foot

Three conditionsReport, if accurate Reason

F32.9 Major depressive disorder, single episode, unspecified

F32.0—F32.5 By severityF33 Major depressive disorder, recurrent

F32.9 does not risk adjust

E11.9 Type 2 diabetes, uncomplicated

If the patient has a complication, use it

E11.9 has a lower risk adjustedscore than codes w/complications

I10 hypertension and N18 CKD in the same patient

I12 Hypertensive chronic kidney disease and N18 CKD (by stage)

I12 has a risk adjusted factor, I10 does not

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Transitional Care Management99495 Transitional Care Management Services with the following required elements

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge

Medical decision making of at least moderate

complexity during the service period

Face-to-face visit, within 14 calendar days of discharge

Transitional Care Management99496 Transitional Care Management Services with the following required elements Communication (direct contact, telephone,

electronic) with the patient and/or caregiver within 2 business days of discharge

Medical decision making of at least high

complexity during the service period Face-to-face visit, within 7 calendar days of

discharge

• Phone call, 2 business days

• Physician reviews discharge summary

• Medication reconciliation, no later than visit

• Face-to-face encounter

• Non-face-to-face services by clinical staff or physician/NP/PA

TCM checklist TCM

• Establish relationship with hospital for notification of discharges

• Initial call made within two business days• Document and bill office visit: plan should

include mention of non-face-to-face work done by clinical staff or physician

• Document non-face-to-face work

Medicare and preventive services• G0402 Welcome to Medicare

• G0438 Initial Annual Wellness

• G0439 Subsequent Annual Wellness

• G0101 Cervical or vaginal cancer screening, pelvic and clinical breast exam

• Q0091 Obtaining screening pap smear

Preventive services

• G0101 and Q0091 may be billed with E/M or wellness visit

• Frequency limitations

• Screening not diagnostic ICD-10 code required

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Wellness visits• Staff can check MAC or Medicare website to

see which services patient is eligible for• Use same template for all three visits so

physician can select “wellness” and staff can change to appropriate code, if needed

• Data collection may be done by staff• Template for wellness visit opened when

patient is roomed

Problem oriented visit and wellness• Some physicians bill for a problem oriented visit

on the day of a wellness visit: patient will have co-pay

• Some physicians add on a wellness visit to a problem oriented visit: no unexpected co-pay; staff reviews schedule and selects patients for whom this can be done

• No part of documentation for wellness visit can be used to select level of E/M service

Advance care planning

• May be done on same day as E/M, except critical care (office, hospital, nursing home)

• May be done with the patient and/or family member or surrogate

• Forms may be completed, but not required

• Uses CPT time rule

Advance care planning

• $0 patient liability when performed same day as AWV

• Append – 33 modifier to ACP code

Non-face-to-face prolonged care

• Codes 99358 & 99359 recognized by Medicare

• May be performed on the same or different day than an E/M service, but must relate to an E/M service

• Physician/NP/PA time only, not clinical staff members

Orphan procedures

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This service requires case management, software support

Modern Healthcare article 10/17/15: 35 million eligible beneficiaries, only 100,000 billed

Other revenue opportunitiesChronic care management, effective 1‐1‐15

• Run CPT frequency

• Select E/M metric and report to providers monthly

• Review variation in TCM, wellness visits

• Review frequency of wellness visits and problem oriented visits

Practice Recommendations• Add TCM and wellness visit

practice support

• Review charging for nurse visits

• Identify unusual 99212, 99214 %

• Injections/immunizations—administration codes

• Review of split visits

• Coding review in support of revenue—not just compliance

Practice Recommendations• Diagnosis coding support for

risk based

• Pulmonary services: nebulizer, instruction

Questions

Thank You!

Betsy Nicoletti

• www.betsynicoletti.com

• www.codingintel.com

• betsy@betsynicoletti.com

• Follow me on twitter @BetsyNicoletti

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Established

OV

99211 2.64%

99212 2.84%

99213 43.18%

99214 48.40%

99215 2.94%

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DOCUMENT TIME IN THE MEDICAL RECORD!

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