Billing and coding

Advanced Practice Registered Nurses are

Revenue Visible - now we bill for services provided

Medicare

Centers for Medicare and Medicaid Services

A federal program mainly for adults age 65 or older, or younger people with certain disabilities. It does not have income limits. It is the same across the whole country. It uses parts like Part A for hospitals and Part B for doctor visits

Medicaid

A joint federal and state program for people of any age who have low income and limited resources. Rules and benefits can change depending on the state. It covers more long-term care and dental services than Medicare

Private Insurers

United Healthcare

Blue Cross and Blue Shield

• fill out packet and insurance company decides if provider is approved then they come up with amount they cover for services

What drives reimbursement?

DOCUMENTATION

CPT codes (E/M)

• used to drive statistics (like how many people die of heart attack that year)

ICD codes

NPI number

individuals “social security number” for medical services

Process for Billing/Coding

1. Determine

   1. Site of service

      1. outpatient

   2. Type of patient

      1. new

      2. established

2. Choose

   1. Medical Decision Making (MDM)

   2. Total time spent on provision of services

3. Document

   1. Document a medically appropriate history and/or examination to support MDM or time spent

New or Established patient

You transfer to a new practice and assume the care of patient within the practice?

Established

New or Established Patient

You transfer to a new practice. A patient that you have seen within the last 3 years schedules an appointment with you?

New

New or Established Patient

A patient presents to you for primary care. This is your first encounter, but the patient has been seen by cardiology in your group practice?

New

You work for a hospital organization in the outpatient clinical setting. A patient has been seen at location A and now presents to be seen at location B?

Established

You are an FNP on call for a group primary care practice and receive a call from an established patient with another provider, but is new to you?

Established

You are an FNP on call for the cardiology group you work for. You receive a call from an established patient with another provider, but is new to you?

Established

Medical decision making guidelines

Extensive clarifications provided in the guidelines to define the elements of MDM

4 levels:

• straightforward

• low

• moderate

• high

Time

Total time spent with the patient on the date of the encounter

• Including non-face-to-face services

• Clear time ranges for each code

3 elements to guide level of MDM

number and complexity of problems addressed

amount and/or complexity of data reviewed and analyzed

risk of complications and/or morbidity or mortality of patient management

Summary chart for codes and MDM and Time

New vs Established patient

1ST ELEMENT - Number and Complexity of Problems

Chart summary for straightforward, low, moderate, high

Definitions for

• minor/self-limited problem

• Stable, chronic illness

• Acute, uncomplicated illness/injury

• Acute Complicated injury

• insect bite

• BPH

• urinary tract infection

• pyelonephritis

Must have sufficient evidence in your documentation to support you reviewed medical issues (ex T2DM: reviewed average BG, diet, exercise, foot care, etc)

Must reflect that problems were sufficiently evaluated and/or treated

Simple notation of another professional managing a problem without additional assessment or care coordination does not qualify

Referral without evaluation or consideration of treatment does not qualify as being addressed or managed

2ND ELEMENT - Amount and/or complexity of data to be reviewed

Data are divided into three categories:

• Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number)

• Independent interpretation of tests (not separately reported)

• Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source

Chart summary for 2ND ELEMENT - Amount and/or complexity of data to be reviewed

Chart summary for 2ND ELEMENT - Amount and/or complexity of data to be reviewed = continued 2

Chart summary for 2ND ELEMENT - Amount and/or complexity of data to be reviewed = continued 3

3RD ELEMENT - Risk of complications and/or morbidity or mortality of patient

new under moderate = social determinants of health

new under high = decision not to resuscitate or deescalate care d/t poor prognosis

Time requirements and things NOT included

Requirements:

• A face-to-face encounter

• Time spent on date of the encounter

• Non-face-to-face activities performed the same calendar day

Do NOT include:

• Time spent by office staff

• Time spent on any other calendar day

Chart summary of EM codes according to time

Time components

Preparing to see the patient (e.g., review of tests) •

Obtaining and/or reviewing separately obtained history •

Performing a medically appropriate examination and/or evaluation •

Counseling and educating the patient/family/caregiver • Ordering medications, tests, or procedures •

Referring and communicating with other healthcare professionals (when not separately reported) •

Documenting clinical information in the electronic or other health record •

Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver o

• Example: Interpreting results of an ECG. •

Care coordination (not separately reported)

Prolonged Servies codes

CMS code G2212

• With or without direct patient contact.

• Do not report for any time unit less than 15 minutes

CMS code 99358

• Non-face-to-face

• 30-60 minutes in a single day

• Date other than the date of the encounter

Justifiable documentation of time

Itemization NOT required

Documentation must accurately reflect services rendered

Avoid overstating the actual time spent

How to describe time documentation

Documentation of time should describe what was done and time spent

• Example: “I spent a total of 25 minutes reviewing the patient’s diagnostic tests, seeing the patient, talking with the nurse, and documenting in the record.” This justifies a 99202 visit for a new patient or a 99213 visit for an established patient. It is NOT necessary to denote time spent in each activity

How to Determine whether or not to use MDM or time?

Consider

• Time: if considerable time is spent collecting the history or performing the exam, or considerable time is spent on patient education

• MDM: if several tests are ordered, consult with other providers are consulted, complex data are reviewed

• Time: if the patient is medically complex (e.g., a level 5 E/M), but time spent is excessive

Documentation that must be included on patient encounter?

1.Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results

2. Assessment, clinical impression, or diagnosis

3. Medical plan of care

4. Date and legible identity of the observer

Why do we document?

• to evaluate and plan the patient’s immediate treatment

• to monitor his/her healthcare over time

• communication and continuity of care

• timely claims review and payment

• appropriate utilization review and quality of care evaluations

• collection of data that may be useful for research and education

LEGAL COMPLAINTS!!

If the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred

• Past and present diagnoses should be accessible to the treating and/or consulting physician

• Appropriate health risk factors should be identified

• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented

• The CPT and ICD codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record

Tips for documentation

An “abnormal” without elaboration is not sufficient

• Note normal/negative findings by a brief statement related to unaffected area(s) or asymptomatic organ systems(s)

• Ancillary staff may document the HPI, PFMS history and review of systems

• Provider should verify the information, update if applicable, and indicate verification

• The physical exam and medical decision-making activities must be performed by the QHP

Legible • Acronyms • Consistent

• Ex: Diagnosis listed as right hemiparesis, but neurological assessment is documented as normal

• Avoid generic documentation: For example, list specific documents reviewed and the results or how the documents relate to the patient, rather than just stating “external documents reviewed”

ICD Code

make them as specific as possible

Ex: E11 vs E11.21 (more specific)

Rules to get Highest level of specificity of ICD

1.Helps assure appropriate reimbursement

2. Avoid unbillable & codes that are not reimbursable.

• Ex: asthma, unspecified

3. Document signs and symptoms in the absence of a confirmed diagnosis

4. Align CPT code with the ICD code to avoid a rejected claim

• Ex of unaligned codes: coding the performance of a skin biopsy under a diagnosis code of diabetic nephropathy

5. Diagnosis management requires a link of each diagnosis to an action (e.g., a prescription, test, etc.). Simply stating that the condition is managed by another provider is not sufficient

6. Capture all important details of the patient management

• Ex: Homelessness code (Z59.0) or extreme poverty (Z59.5) addresses social determinates of health and helps support a higher level of medical decision making

Responsibilities of provider

Every provider is legally responsible for assigning the appropriate codes according to the services provided and knowing how their provider number (NPI) is being utilized

It is your professional obligation to be vigilant in avoiding unethical and fraudulent billing practices

You are responsible for submitting accurate claims

E/M coding is for services that you provided

Services provided must fall within your scope of practice