Billing and Coding Conference - The University of Chicago · Billing and Coding Conference ... if I...

Billing and Coding Conference

February 26th 2013

University of Chicago Section of Hospital Medicine


Agenda

1.  Hospital Medicine Coding Pattern

2.  Tips to maximize individual billing

3.  Billing audit

4.  .SPLITSHAREDNPPVISIT

5.  Basic Coding Guidelines – focus on Decision Making

examples from http://thehappyhospitalist.blogspot.com

6.  Observation Coding

7.  Advanced Coding / Billing

8.  ICD 10 update

9.  Q&A


Levels of Service – Section of Hospital Medicine

FY2014

Admission Level 1 99221 0.6%

Level 2 99222 4.6%

Level 3 99223 94.8%

Subsequent Level 1 99231 0.4%

Level 2 99232 5.1%

Level 3 99233 94.5%

Discharge Level 1 99238 93.0%

Level 2 99239 7.0%


Levels of Service – Section of Hospital Medicine

FY2014 FY2012

Admission Level 1 99221 0.6% 5.1%

Level 2 99222 4.6% 12.5%

Level 3 99223 94.8% 82.4%

Subsequent Level 1 99231 0.4% 1.5%

Level 2 99232 5.1% 19.6%

Level 3 99233 94.5% 78.9%

Discharge Level 1 99238 93.0% 97.2%

Level 2 99239 7.0% 2.8%


Admission Subsequent Day Discharge

99221 99222 99223

RVUs 1.92 2.61 3.86

Billed $296 $399 $489

Collected $84 $114 $152

99231 99232 99233 99238 99239

Levels of Service

RVUs 0.76 1.39 2.00

Billed $150 $212 $289

Collected $33 $61 $88

RVUs 1.28 1.90

Billed $221 $276

Collected $56 $83


CPT® description 2012 TABLE CPT® (wRVU)

high level in-patient admit 99223 3.86

high level in-patient consult 99255 4.0

high level in-patient follow-up 99233 2.0

>30 minutes in-patient discharge 99239 1.9

critical care initial 99291 4.5

critical care add on 99292 2.25

prolonged service initial in-patient 99356 1.71

prolonged service add on in-patient 99357 1.71

central line 36556 2.5

paracentesis 49082 1.24

lumbar puncture 62270 1.37

thoracentesis 32421 1.54

CPR/Resuscitation 92950 4.0

smoking cessation counseling 3-10 min 99406 0.24

smoking cessation counseling > 10 min 99407 0.5


CPT® description 2012 TABLE CPT® (wRVU) #

high level in-patient admit 99223 3.86 2,242

high level in-patient consult 99255 4.0 201

high level in-patient follow-up 99233 2.0 8,994

>30 minutes in-patient discharge 99239 1.9 170

critical care initial 99291 4.5 44

critical care add on 99292 2.25 11

prolonged service initial in-patient 99356 1.71 32

prolonged service add on in-patient 99357 1.71 5

central line 36556 2.5 4

paracentesis 49082 1.24 9

lumbar puncture 62270 1.37 0

thoracentesis 32421 1.54 1

CPR/Resuscitation 92950 4.0 0

smoking cessation counseling 3-10 min 99406 0.24 1

smoking cessation counseling > 10 min 99407 0.5 0


Billing tips for maximizing individual billing

We used the top 3 billers’ comments from FY2013 to assembly this list

1.  I keep list of my patients with level of billing noted if I don’t bill in the day of service

2.  I try to bill higher level supported by documentation every single time

3.  I bill extended visit for family meetings

4.  I bill critical care when I can

5.  On busy days I tend to take extra patients or minimize the hands off to nights while on Bridge

6.  I bill for smoking counseling, prolonged care, critical care whenever possible


Billing Audit

Weekly billing audit

-  We use Schedule vs Billing report and after a 7 day grace period we report number of days delayed for each day on service without billed encounters

-  We compare the billing data with census data and we eliminate the shifts that could have 0 billable encounters (Bridge, LG, Weekend nights)

-  Currently we report deindentified data and follow-up on the effect of this measure

-  We will automate the process with a series of 3 emails at one, two and three weeks, escalating the recipients for each email


.SPLITSHAREDNPPVISIT

“When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician

and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M

encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN

number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if

the physician participated in the service by only reviewing the patient’s medical record) then the service may

only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule

rate based on the UPIN/PIN entered on the claim.”

* Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (Rev. 2848, 12-30-13)


.SPLITSHAREDNPPVISIT

Documentation by the attending physician should include:

1.  an attestation that unequivocally demonstrates their personal encounter with the patient

2.  the name of the individual with whom the service is shared/split

3.  each provider must document their portion of the rendered service

4.  date and legibly sign their corresponding note

I personally performed a substantive portion of this patient encounter in conjunction with ***. The patient

presents with ***. On physical examination, I personally found ***. My impression/plan is ***.


Basic Coding Guidelines

Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a

management option, which is determined by considering the following factors:


Medical Decision Making


Documentation Requirements HISTORY C/C and 4 elements of the HPI (character, onset, location, duration,

associated signs etc or the status of 3 chronic medical conditions.

and 2 review of systems and 1 area from Past Medical, Medications, Allergies, Family, Social

history AND EXAM Extended exam of the affected body area and other symptomatic or

related organ systems or 6 areas (2 bullets each) or 2+ areas (12 bullets total). Documenting three vitals is considered a bullet

AND DECISION MAKING One diagnosis

Example C/C: My leg is red HPI 28 yo Male with 3 day history left calf pain. 6/10,

dull, constant. Associated edema,

erythema. PMH Smoker Exam 120/80 85 102.7 temp, well appearing

heart: RRR without murmur, good femoral pulses

lungs: clear to auscultation, normal effort

abdomen: soft, no palpable liver

Skin: erythema lines marked and noted,

induration present Musculoskeletal: normal ROM knee, no clubbing,

cyanosis ROS: No CP or SOB Labs none. No xrays Impression Cellulitis Plan IV access and antibiotic administration

CPT® 99221




and 10+ review of systems and All 3 areas documented: Past History (things like medical,

medications, allergies) AND Family History AND Social History

AND EXAM 1995 Guidelines: 8 or more systems documented 1997 Guidelines: 9 areas with two bullets each AND DECISION MAKING 2 out of 3 Number of diagnoses and management options: 3 points Amount and complexity of data to be reviewed: 3 points Table of risk: Moderate risk.


dull, constant. Associated edema,

erythema. PMFSH On no meds. Smoker, Mother with eczema

ROS Except as dictated above, all other systems were

reviewed and otherwise negative

Exam 120/80 85 102.7 temp, well appearing

(HENT): Normal Eyes: Normal CV: Normal Respiratory: Normal GI: Normal Psychiatric: Normal Skin: Edema, warmth, redness right leg, lines

consistent with cellulitis, marked with skin

marker. Labs WBC 13K Impression Cellulitis Plan Antibiotics. Reviewed with ER physician.

CPT® 99222




and 10+ review of systems and All 3 areas documented: Past History (things like medical,

medications, allergies) AND Family History AND Social History

AND EXAM 1995 Guidelines: 8 or more systems documented 1997 Guidelines: 9 areas with two bullets each AND DECISION MAKING 2 out of 3 Number of diagnoses and management options: 4 points Amount and complexity of data to be reviewed: 4 points Table of risk: High risk.


dull, constant. Associated edema, erythema.

PMFSH On no meds. Smoker, Mother with eczema

ROS Except as dictated above, all other systems were

reviewed and otherwise negative

Exam 120/80 85 102.7 temp, well appearing

(HENT): Normal Eyes: Normal CV: Normal Respiratory: Normal GI: Normal Psychiatric: Normal Skin: Edema, warmth, redness right leg, lines

consistent with cellulitis, marked with skin

marker. Labs WBC 13K Venous doppler report reviewed. No clot.

Impression Cellulitis Plan Antibiotics. Reviewed with ER physician.

CPT® 99223


Minimum Documentation Requirements 2 OUT OF 3 HISTORY 1 element of the HPI (character, onset, location, duration,

associated signs etc) or the status of 3 chronic medical conditions.

EXAM 1 organ system DECISION MAKING 2 out of 3 Number of diagnoses and management options: 1 points Amount and complexity of data to be reviewed: 0 points Table of risk: Minimum risk.

Example 1 No pain 120/80 80 Tmax 98.9 (three vital signs)

A P

CPT® 99231

Example 2 S 120/80 80 Tmax 98.6

HTN, controlled P


Minimum Documentation Requirements 2 OUT OF 3 HISTORY One HPI (Character, onset, location, duration...) OR the status of

three chronic medical condition and One ROS

EXAM 2 organ system (1995 Guidelines) 6 bullets (1997 Guidelines) DECISION MAKING 2 out of 3 Number of diagnoses and management options: 3 points Amount and complexity of data to be reviewed: 3 points Table of risk: Moderate risk.

Example 1 sharp pain in abd, no SOB

120/80 70 Tm 98.6 Alert, reg pulse, no wheezing, no leg

edema, no rash (6 bullets)

A P

CPT® 99232

Example 2 No SOB 120/80 70 Tm 98.6 Alert, reg pulse, no wheezing, no leg

edema, no rash HTN, stable COPD, stable CAD, stable P


Minimum Documentation Requirements 2 OUT OF 3 HISTORY 4 HPI (Character, onset, location, duration...) OR the status of three

chronic medical condition and 2 ROS

EXAM 6 areas with 2 bullets each or 12+ bullets in 2+ areas DECISION MAKING 2 out of 3 Number of diagnoses and management options: 4 points Amount and complexity of data to be reviewed: 4 points Table of risk: High risk.

Example 1 RLQ abdominal pain, sharp, started yesterday,

constant no CP, no SOB 120/80 80 Tm 98.6 Alert, anxious, regular rhythm, normal femoral

pulses, lungs clear, normal respiratory

effort, bowel tones present, no tenderness,

no clubbing, no synovitis, no rash

A P

CPT® 99233

Example 2 S 120/80 80 Tm 98.6

Alert, anxious, regular rhythm, normal femoral

pulses, lungs clear, normal respiratory effort,

bowel tones present, no tenderness, no

clubbing, no synovitis, no rash

Labs INR 1.7 on coumadin

CXR film personally reviewed-normal

Discussed antibiotic options with Dr Smith

A P


Face-to-face evaluation and management (E/M) service

between the attending physician and the patient. The E/M discharge day management visit shall be reported

for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date.

Only one hospital discharge day management service is

payable per patient per hospital stay. Only the attending physician of record reports the discharge

day management service. Physicians or qualified nonphysician practitioners, other than

the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT® code range 99231 – 99233) for a final visit.

Example Patient seen and evaluated in the day of

discharge

D/C time 35 minutes

CPT® 99238/99239


Observation Coding Guidelines

Scenario

Observation care for less than 8 hours on the same

calendar date

Admitted for observation care and discharged on a different calendar date

Observation care for 3 days

Observation care for a minimum of 8 hours, but less

than 24 hours, and is discharged on the same calendar date

CPT Code to be used Initial Observation Care (99218 – 99220); Observation Care Discharge Service (99217) shall not be used Initial Observation Care (99218 – 99220) and Observation Care Discharge (99217). Initial Observation Care (99218-99220) and Subsequent Observation Care (99224-99226) and Observation Care Discharge (99217) Admission and Discharge Services (99234 –

99236)


Observation Coding Guidelines

Scenario

Patient admitted to inpatient status before the end of

the date on which the patient began receiving hospital outpatient observation services

Patient admitted to inpatient status from hospital

outpatient observation care subsequent to the date of initiation of observation services

CPT Code to be used

Initial Hospital Visit (99221 – 99223) Initial Hospital Visit (99221 – 99223) shall not bill the hospital observation discharge management (99217) or other codes

The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. * Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (Rev. 2848, 12-30-13)


1. Billing 2 E/M Codes in the same group in the same day

“When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service” CMS

2. Smoking Cessation Counseling

If the patient is symptomatic

99406 for greater than 3 minutes up to 10 minutes of counseling (intermediate)

99407 for greater than 10 minutes of smoking cessation counseling (intensive)

Advanced Billing


3. Prolonged Service Codes

CPT® 99356 (inpatient prolonged service codes)

30 to 60 minutes of additional time past the threshold time of the original code

(99231 – 15min, 99232 – 25min, 99233 – 35min)

CPT® 99357 (inpatient additional prolonged service codes)

once you have met the threshold for 99356 (60 minutes) you can bill a 99357 for every additional

30 minutes (minimum of 15 minutes).

You must document the total time spent during the face-to-fact portion of the encounter, and the additional unit or floor time in an additional note or one cumulative note.

Advanced Billing


Billing System -  DOM Billing system will receive a facelift in the next couple of months

-  Improved patient list management – easier to build your list and maintain it updated, last date billed, etc

-  Enhanced charge entry options -  ICD 10 Epic search engine will be integrated into the billing system

-  The ICD 10 search engine is an interactive tool that asks for required details in order to generate the right diagnosis code (e.g. CHF / Systolic / Acute vs Chronic, etc)

-  Mercy billing integration to follow

EPIC Billing Module - At least 2 years away Provider training -  The Precise learning system provider training for all MDs/NPP to start in the next couple of

months

ICD 10 updates


Questions and Answers

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