3

Department of Optometry

Office of Billing Compliance: Coding, Billing & Documentation

2016

3 3

Why Are We Here?

• To EDUCATE and PROTECT our providers and organization

• To provide your department/practice with every tool you need to maximize compliance and get paid what you deserve

• To update you on the latest CMS/OIG activities related to your specialty

• To give you confidence in your coding and documentation!

2

3

2016 Code Changes

3

3 3

4

• Code Changes - Eye & Ocular Adnexa • 65785 Implantation of intrastromal corneal ring segments • The 2016 CPT® code set adds 65785 to report a new procedure,

intrastromal corneal ring segment implantation. Use 65785 to report when the provider implants thin semicircular or crescent-shaped soft plastic rings into channels created in the outer edges of the cornea (the transparent covering on the front of the eye) to correct its shape.

• The provider performs this procedure to treat keratoconus, a degenerative disease that changes the shape of the cornea and results in distorted vision, or to treat mild to moderate nearsightedness (myopia).

New Codes For 2016

3 3

Revised CPT Codes

• 65855 – Trabeculoplasty by laser surgery; • 67227 – Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), cryotherapy, diathermy; • 67228 – Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation. The “one or more sessions” verbiage was removed from these three procedures.

5

3 3

Revised CPT Codes The following codes contain language changes reflected by underlines: • 67101 – Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, including drainage of subretinal fluid when performed; • 67105 – photocoagulation including drainage of subretinal fluid, when performed; • 67107 – Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid; • 67108 – … with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique; • 67113 – Repair of complex retinal detachment … with vitrectomy and membrane peeling including, when performed, air, gas, or silicone oil, tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens; • 99174 – Instrument-based ocular screening (e.g., photo screening, automated-refraction), bilateral; with remote analysis and report.

6

3 3

Why Does Documentation Matter?

IT’S OUR AGREEMENT WITH MEDICARE AND OTHER INSURANCE COMPANIES

CORRECT CODING PRACTICE IS PART OF GOOD MEDICAL CARE

CIVIL AND CRIMINAL VIOLATIONS ARE HANDED DOWN EACH YEAR FOR FRAUDULENT CODING

MILLIONS OF DOLLARS ARE LOST EACH YEAR TO POOR CODING PRACTICES

7

3

Visit Coding Decision Optometrists can select either the “eye codes” or E/M visit

codes for their services. • Choosing Correct Codes

• Most Optometrists prefer using the Eye Codes, believing they are easier to use and more audit-proof. That is not necessarily so. If you use only eye codes, not only are you punishing yourself financially, but you also may be found to be upcoding or downcoding under audit. For example, the intermediate eye code for established patients (CPT code 92012) is not always suitable for coding frequent follow-ups such as follow-up examination for corneal abrasion. (The correct code for healing corneal abrasion often usually is E/M code 99212).

• The Center for Medicare and Medicaid Services (CMS) wants you to code correctly — to neither upcode nor downcode.

• Typically eye codes are billed in the OP setting for visits related to “routine” eye follow-ups or complaints.

• E/M codes are usually billed for specific eye injury, complaint or IP services.

8

3 3

THE THREE KEY DOCUMENTATION ELEMENTS

MEDICAL DECISION-MAKING HISTORY

PHYSICAL EXAM

How does medical necessity fit into these components?

Knowing the answer to this question will help you to select E/M codes and reduce audit risk.

Nuts and Bolts of E&M Coding

9

3 3

• The Nature of the Presenting Problem (NPP) determines the level of documentation necessary for the service

• The level of care (E&M service) submitted must not exceed the level of care that is medically necessary

SO . . .

• Medical Decision-Making and Medical Necessity related to the “NPP” determine the maximum E&M service.

• The amount of history and exam alone do NOT.

Important!

10

3 3

NEW PATIENT = 3 OUT OF 3 ELEMENTS

IMPORTANT!

ESTABLISHED PATIENT = 2 OUT OF 3 COMPONENTS

(MDM PLUS APPROPRIATE HISTORY OR EXAM)

History / Physical Exam / Medical Decision-Making

11

Medical Decision Making (MDM) DOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE TODAY!!

• Number of possible diagnoses and/or management options affecting todays

visit. List each separately in A/P and address every diagnosis or management option from visit. Is the diagnosis and/or management options : • “New” self-limiting: After the course of prescribed treatment it is anticipated

that the diagnosis will no longer be exist (e.g. otitis, poison ivy, …) • New diagnosis with follow-up or no follow-up: Diagnosis will remain next visit • Established diagnosis that stable or worse

Step 1:

• Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. • Labs, radiology, scans, EKGs etc. reviewed or ordered • Review and summarization of old medical records or request old records • Independent visualization of image, tracing or specimen itself (not simply

review of report)

Step

2:

• The risk of significant complications, morbidity, and/or mortality with the patient’s problem(s), diagnostic procedure(s), and/or possible management options. • # of chronic conditions and are the stable or exacerbated (mild or severe) • Rxs ordered or renewed. Any Rx toxic with frequent monitoring? • Procedures ordered and patient risk for procedure

Step 3:

Note: The 2 most complex MDM steps out of the 3 will determine the overall level of MDM 12

3 3

Medical Decision-Making

1. Number of Diagnoses or Treatment Options

Multiple active problems?

New problem with additional workup?

Are problems worse?

HIGHER

COMPLEXITY

One or two stable problems?

No further workup required?

Improved from last visit? =

LOWER

COMPLEXITY

=

13

3 3

Medical Decision-Making

2. Amount/Complexity of Data

• Were lab/x-ray ordered or reviewed? • Were other more detailed studies ordered? (Echo, PFTs, BMD, EMG/NCV, etc.) • Did you review old records? • Did you view images yourself? • Discuss the patient with consultant?

14

3

Medical Decision-Making

3. Table of Risk

• Is the presenting problem self-limited? • Are procedures required? • Is there exacerbation of chronic illness? • Is surgery or complicated management

indicated? • Are prescription medications being

managed?

15

16

MDM – Step 3: Risk

Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected

Min • One self-limited / minor problem (subconjunctival Hemorrhage)

• Tonometry • PAM • Contrast sensitivity • Schimir’s test • Topical diagnostic agent (rose bengal) • Ultrasound • Color Vision • Visual field • Lab tests requiring venipuncture

• Rest • Elastic bandages • Gargles • Superficial dressings

Low • 2 or more self-limited/minor problems • 1 stable chronic illness (controlled

glaucoma) • Acute uncomplicated illness / injury

(simple sprain)

• Gonioscopy • Ophthalmodynamometry • Conjunctival culture • Oral FA • Provocative glaucoma test • MRI/MRA

• OTC meds • Minor surgery w/no identified risk

factors • Occlusion • Pressure Patch • IV fluids w/out additives

Mod • 1 > chronic illness, mod. Exacerbation, progression or side effects of Tx

• 2 or more chronic illnesses • Undiagnosed new problem w/uncertain

prognosis (red eye) • Acute illness w/systemic symptoms

(facial palsy with corneal exposure) • Acute complicated injury

• Corneal Culture • Retrobulbar injection • Deep needle biopsy or incisional biopsy • Physiological stress tests

• Prescription meds • Minor surgery w/identified risk factors • Elective major surgery w/out risk

factors • Therapeutic nuclear medicine • IV fluids w/additives

High • 1 > chronic illness, severe Exacerbation, progression or side effects of Tx

• Acute or chronic illnesses that may pose threat to life or bodily function (trauma, endophthalmitis, retinoblastoma, malignancies, angle closure)

• Abrupt change in neurologic status (TIA, seizure)

• Vitreous tap • Anterior Chamber tap • Fine needle biopsy – orbital, ocular

• Elective major surgery w/risk factors • Emergency surgery • Parenteral controlled substances • Drug therapy monitoring for toxicity • DNR

OPTOMETRY TABLE OF RISK

3 3

Ignoring how medical decision-making affects E/M leveling can put you at risk.

• According to the Medicare Claims Processing Manual, chapter 12, section 30.6.1:

• Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

• That is, a provider should not perform or order work (or bill a higher level of service) if it’s not “necessary,” based on the nature of the presenting problem.

Medical Necessity

17

3 3

• The definitions of medical necessity are important, but it’s how they get applied in the claims adjudication process that gives them shape.

• In other words, when it comes to selecting the appropriate level of care for

any encounter, medical necessity trumps everything else, including the documentation of history, physical exam. For physicians this could mean that even “bullet-proof” documentation of these key components will not ensure protection if auditors find that the medical necessity is lacking.

Medical Necessity

18

3 3

• The best way to stay within the bounds of medical necessity is to think of each element of the history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so.

• Each component of the history would yield clinically relevant information.

• First, you would take an extensive history of the present illness (HPI) to further describe the NPP.

• Ask about the patient’s PMH to identify potential risk factors. • Ask about FH if it would affect your decisions that visit. • Finally, because the spectrum of differential diagnoses for this problem is so

broad, you would be justified in performing a complete review of systems (ROS) to uncover clues that may point you in the right medical direction.

Medical Necessity

19

3 3

• The same logic applies to performing a comprehensive physical exam on this patient. Because the etiology of the issue or NPP is unknown or unstable, sound medical practice would dictate that a comprehensive exam be performed to help guide diagnosis and treatment.

Medical Necessity

20

3 3

• Perform and document only those elements of history and exam that are necessary to take good care of the patient.

• If the final history and exam fulfill the requirements for the MDM of code too, then this is the code to bill.

• When the MDM documentation falls short of the requirements for the code, use a lower level code.

Medical Necessity

21

3 3

• To ensure that the level of care you select matches the intrinsic medical necessity of the encounter, let the key component of medical decision making be your guide. Because it is based on the number and nature of the clinical problems as well as the risk to the patient, the complexity of your medical decision making may be a reliable surrogate for the vaguely defined concept of medical necessity.

• Practitioners often estimate the medical decision making early in the

encounter before they start to document the history and exam. Let the medical decision making point you toward the appropriate code.

Medical Necessity

22

3 3

FOUR ELEMENTS of HISTORY

• Chief Complaint (CC:) • History of Present Illness (HPI)

location/quality/severity/duration/timing/context/ modifying factors/associated symptoms

• Past/Family/Social History (PFSHx) • Review of Systems (ROS)

23

3

History

1. Chief Complaint • Concise statement describing reason for encounter

(“stomach pain,”, “follow-up diabetes”) • Can be included in HPI

• IMPORTANT:

• The visit is not billable if Chief Complaint is not somewhere in the note

• Must be “follow-up” of _______________________

24

3 3

HPI • Status of chronic conditions being managed at visit

• Just listing the chronic conditions is a medical history • Their status must be addressed for HPI coding

OR

• Documentation of the HPI applicable elements relative to the diagnosis or signs/symptoms being managed at visit

• Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated signs and symptoms

25

3

History - PFSHx

3. PAST, FAMILY, AND SOCIAL HISTORY - Patient’s previous illnesses, surgeries, and medications - Family history of important illnesses and hereditary

conditions - Social history involving work, home issues,

tobacco/alcohol/drug use, etc.

- TWO TYPES: PERTINENT: RELATED ONLY TO HPI COMPLETE: 3/3 FOR NEW/CONSULTS

2/3 FOR ESTABLISHED

26

3

History - ROS 4. REVIEW OF SYSTEMS 14 recognized:

• Constitutional Psych • Eyes Respiratory • ENT GI • CV GU • Skin MSK • Neuro Endocrine • Heme/Lymph Allergy/Immunology

THREE TYPES: PROBLEM PERTINENT (1 SYSTEM) EXTENDED (2-9 SYSTEMS) COMPLETE (10 SYSTEMS)

27

3 3

PEARLS FOR HISTORY DOCUMENTATION:

• Must have PAST/FAMILY/SOCIAL history for comprehensive history (ALL THREE)

• Don’t forget 10-system review!

• You cannot charge higher than a level 3 new or consult visit without COMPREHENSIVE HISTORY

History

28

3

EYE 1997 Examination

Eyes

Test visual acuity (Does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexae including lids (e.g., ptosis or lagophthalmos),

lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual

reaction (afferent pupil), size (e.g., anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma,

endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior

capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma

or infectious disease) Ophthalmoscopic examination through dilated pupils (unless contraindicated) of : Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor

elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)

Neurological/ Psychiatric

Brief assessment of mental status including: Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation) 29

3

1997 Eye Physical Exam Definitions Problem Focused (PF)

• ‘97=Specialty and GMS: 1-5 elements identified by bullet.

Expanded Problem Focused (EPF)

• ‘97=Specialty and GMS: At least 6 elements identified by bullet.

Detailed (D)

• 97=Specialty: At least 12 elements identified by bullet (9 for eye and psyc) GNS= At least 2 bullets from each of 6 areas or at least 12 in 2 or more areas.

Comprehensive (C)

• ‘97=Specialty: All elements with bullet in shaded areas and at least 1 in non-shaded area.

30

3 3

• Medicare will allow payment for face-to-face time counseling patient if documented correctly:

• “I spent 40 minutes with the patient, of which >50 % were spent counseling on ________”

• No other documentation necessary • MUST BE FACE-TO-FACE TIME WITH PATIENT OR FAMILY MEMBERS ONLY!! • Also applies for “Coordination of Care” – attending time filling out forms,

arranging appointments, facility transfers, etc., when the patient is present

Time-Based Coding

31

Outpatient Counseling Time: 99201 10 min 99202 20 min 99203 30 min 99204 45 min 99205 60 min 99241 15 min 99242 30 min 99243 40 min 99244 60 min 99245 80 min 99211 5 min 99212 10 min 99213 15 min 99214 25 min 99215 40 min

Inpatient Counseling Time: 99221 30 min 99222 50 min 99223 70 min 99231 15 min 99232 25 min 99233 35 min 99251 20 min 99252 40 min 99253 55 min 99254 80 min 99255 110 min

Time-Based Billing for Counseling or Coordination of Care

32

3

Visit Coding Decision Optometrists can select either the “eye codes” or E/M visit

codes for their services. • Choosing Correct Codes

• Most Optometrists prefer using the Eye Codes, believing they are easier to use and more audit-proof. That is not necessarily so. If you use only eye codes, not only are you punishing yourself financially, but you also may be found to be upcoding or downcoding under audit. For example, the intermediate eye code for established patients (CPT code 92012) is not always suitable for coding frequent follow-ups such as follow-up examination for corneal abrasion. (The correct code for healing corneal abrasion often usually is E/M code 99212).

• The Center for Medicare and Medicaid Services (CMS) wants you to code correctly — to neither upcode nor downcode.

• Typically eye codes are billed in the OP setting for visits related to “routine” eye follow-ups or complaints.

• E/M codes are usually billed for specific eye injury, complaint or IP services.

33

3

Ophthalmology Codes • S0620 Routine ophthalmological examination including refraction;

new patient (not a Medicare Code) • S0621 Routine ophthalmological examination including refraction;

established patient (not a Medicare Code) • 92002 Ophthalmological services: medical examination and

evaluation with initiation of diagnostic and treatment program; intermediate, new patient

• 92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits

• 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

• 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

34

3

S Code Documentation • S0620-1 are defined ‘routine ophthalmological examination, includes

refraction. These are HCPCS codes, not CPT, and as a result, most continue use the 99xxx or 92xxx visit codes, combined with 92015, refraction, to report their eye care visits.

• The word 'routine' in the definition indicates that the visit had no medical reason/chief complaint/presenting problem. Doctors who choose to use the S codes would use them whenever there was no medical reason for the visit, whether the patient has insurance to cover the visit or not. This is further complicated because most of the vision plans that cover the 'non-medical visits' don't accept the use of the S code.

• An advantage in the S codes is that offices can establish fees for their 99xxx and 92xxx office visits as if they are always used for medical cases, reserving the S codes; in most cases with a lower fee; for the visits without a medical reason.

35

3

General Ophthalmologic Services : New 92002-04 & Established 92012-14

13 elements of an ophthalmologic exam including:

• Test visual acuity (does not include determination of refractive error)

• Ocular mobility (required for comprehensive level)

• Intraocular pressure • Retina (vitreous, macula,

periphery, and vessels) • Optic disc • Gross visual fields (required for

comprehensive level)

Illustration by Art Studio and Gallery of Rudolf Stalder

Eyelids and adnexa (required for intermediate level)

Pupils

Iris

Conjunctiva

Cornea

Anterior chamber

Lens

36

3

Comprehensive Examination 92004-92014

• History, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination.

• It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry.

• A new patient always includes initiation of diagnostic and treatment

programs. • An established patient always includes initiation or continuation of

diagnostic and treatment programs.

Includes 9 or more elements and:

37

3

Intermediate Examination 92002-92012

Includes 3 -8 elements and- • Intermediate history • General medical observations • External ocular and adnexal examination • If less than 3 elements are provided, then the service

must be billed with an E/M code.

38

3

Intermediate and Comprehensive Ophthalmological services constitute integrated services in which

medical decision making cannot be separated from the examining techniques used. Ophthalmological codes are appropriate for services to new or established patients when the level of service includes several basic routine optometric/ ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry, and basic sensorimotor examination, that are integrated with and cannot be separated from the diagnostic evaluation.

Diagnosis Codes that Support Medical Necessity • In addition to the general documentation requirements and the specified

number of elements necessary to report a particular level of service, the "reasonable and necessary" requirements for billing Medicare must also be met. Therefore, certain diagnosis codes may not justify the "reasonable and necessary" criteria for reporting a particular level of service.

39

3

Routine Eye Examinations • Medicare does not cover routine eye examinations or refractions

92015 • For “statutory exclusions” (services never covered by Medicare)

Advanced Beneficiary Notice (ABN) is not necessary HOWEVER

• For patients with secondary insurance that may cover these services, a claim can be submitted to Medicare to obtain a formal “denial” of reimbursement

• Explain Medicare coverage policy to the patient • Explain that patient has the choice of having the service • Indicate how much the patient will be financially responsible for • Append appropriate modifier (GY) if you need to obtain a denial

from Medicare to process secondary insurance claim

40

3

Contact Lenses • Proper coding for contact lens exams?

• Patient comes in for routine eye exam and CL fit, code 92004/14 and 92310. If a refraction was done also bill 92015.

• 92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia

• First follow-up exam after the contact lenses are dispensed is included in the 92310, as its definition includes "medical supervision of adaptation".

• Patient presents for a routine eye exam, doesn't want CL's at that visit, but decides a month down the road they now want CL's.

• Code 92310 for the fitting and supervision of adaptation. • If medically necessary for a specific patient a limited examination

to be sure no eye changes have occurred.

41

3

Optometry Technician vs Optometry Student

For billing purposes, a billing practitioner can utilize the below services only, when performed by a technician or student, if referenced in their note:

• Optometry Technician can perform and document: • Visual acuity • Intraocular pressure (IOP) • Confrontation visual field exam

• Optometry Student can perform and document: • ROS and PFSH in an E/M service

42

3 3

Patient not seen by you or your billing group in the past three years (as outpatient or inpatient)

New Patients

43

3 3

Florida Medicare Focused Audits 2016

44

3 3

Optometrist Current Audit Procedures • 76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry,

unilateral or bilateral (determination of corneal thickness) • 92060 Sensorimotor examination with multiple measurements

of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)

• 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral

• 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

• 92020 Gonioscopy (separate procedure) • 92065 Orthoptic and/or pleoptic training, with continuing

medical direction and evaluation • 92250 Fundus photography with interpretation and report

45

46

CPT Code Desc Justification CC: Blurred Vision

92020 Gonioscopy (separate procedure) Evaluate angle structures; baseline exam; monitor

92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report

Examine for corneal surface abnormalities; corneal distortion due to bad images

92060

Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)

Evaluate phoria in all positions of gaze; no significant change from previous test (THIS IS A NEW PATIENT: DOCUMENT PREVIOUS TEST!)

92083

Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2)

Rule out cause for current symptoms (blurry vision in both eyes)

92250 Fundus photography with interpretation and report

Document and monitor progression of choroidal atrophy

99203 New Office

3 3

47

CPT Code Desc Justification CC: Blurry Vision

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

Glaucoma suspect or screening; corneal thickness above normal value

92025

Computerized corneal topography, unilateral or bilateral, with interpretation and report

Comparison study. Central Cone. No significant change compared to prior study. (THIS IS A NEW PATIENT: DOCUMENT PREVIOUS TEST!)

92132

Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral

Angle and anterior chamber evaluation; monitor progression/changes

92133

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

Evaluate for glaucoma due to large cup/disc ratio

99204 New Office

48

CPT Code Desc Justification CC: Diabetic Eye Disease

92014

Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

92015 Determination of refractive state

92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report

Evaluate corneal health, cause and/or progression of astigmatism, rule out or diagnose keratoconus, rule out causes of decreased visual acuity.

92083

Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2)

Rule out cause for current symptoms (blurry vision in both eyes)

92250 Fundus photography with interpretation and report Document large physiologic cupping (c/d ratio)

3 3

Lacrimal Punctum Plugs (10 Day Global) 68801 - Dilation of lacrimal punctum, with or without irrigation Covered if diagnosed with one of the following conditions: –Dry eye syndrome of the lacrimal glands (right, left, bilateral, or unspecified)

–Keratoconjunctivitis sicca, not specified as Sjögren’s (right, left, bilateral, or unspecified) –Lagophthalmos –Chemical burns –Ocular pemphigus –Severe punctate keratitis –Other similar serious anterior segment conditions

Documentation of: • Complaints that are normally associated with dry eye syndrome. • Have a positive Schirmer's test or some other measurement of lacrimal gland

deficiency or evidence of corneal decomposition by slit lamp exam. • Have undergone two to four weeks of conventional treatment using eye drops, gels, or

ointments. • Show no evidence of any improvements after conventional treatments.

Provider must maintain the following documentation for each claim submitted for reimbursement in the recipient’s medical record: Diagnosis code supporting the medical necessity for the procedure. • Results of Schirmer’s test or equivalent tear break-up time, tear assay, zone-quick

and slit lamp exam.

49

3 3

Modifier -25

• Signifies visit or consultation for a SIGNIFICANT, SEPARATE identifiable E/M service on the same day

• Example - visit for floaters follow-up/patient also receives an intravitreal injection for Wet AMD.

Common Modifiers

50

3 3

Modifier-24 (Surgery modifier):

• Unrelated E&M service by the same physician during a post-op period

Modifier -59 • two services performed at different anatomical sites on the

same day on the same patient

Common Modifiers

51

3 3

NUMBER DIAGNOSES IN ORDER OF IMPORTANCE ON CHARGE TICKET

Include all diagnoses you addressed!!

Some insurance companies (VIVA Medicare) increase cap payments based on # of diagnoses

Coding Pearls of Wisdom

NEVER WAIVE CO-PAYS! (friends, family, MDs or their families, etc.)

There are rare exceptions regarding patient’s financial hardship but a reasonable attempt to collect must still be documented

52

3 3

• Complaints from patients or “whistleblowers” - nurses, employees, etc.

• Disproportionate volumes of high level services (Level 4s and 5s) • Lack of documentation of medical necessity for services rendered • Unrelated specialty procedure billing • Uniform level coding (i.e. all Level 4s)

What Initiates a Medicare Audit?

53

3

Billing Services When Working With Residents Fellows and Interns

All Types of Services Involving a resident with a TP Requires

Appropriate Attestations In EHR or Paper Charts To Bill

Teaching Physicians (TP) Guidelines

54

3 3

Evaluation and Management (E/M) E/M IP or OP: TP must personally document by a personally selected macro in the EMR or handwritten at least the following:

• That s/he was present and performed key portions of the service in the presence of or at a separate time from the resident; AND

• The participation of the teaching physician in the management of the patient.

• Initial Visit: “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with a corneal tear. Will begin treatment with……...”

• Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

• Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

• Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note. This is consistent with Nodular episcleritis will start with FML® suspension q.i.d. and f/up in 4 days. .”

The documentation of the Teaching Physician must be patient specific.

55

3

•Assessed and Agree •Reviewed and Agree •Co-signed Note •Patient seen and examined and I agree with the note

•As documented by resident, I agree with the history, exam and assessment/plan

56

Unacceptable TP Documentation

3 3

Evaluation and Management (E/M) Time Based E/M Services: The TP must be present and document for the period of time for which the claim is made. Examples :

• E/M codes where more than 50% of the TP time spent counseling or coordinating care

Medical Student/Optometry Student documentation for billing only counts for ROS and PFSH. All other contributions by the medical/optometry student must be re-performed and documented by a resident or teaching optometrist.

57

3

Minor – (< 5 Minutes): For payment, a minor procedure billed by a TP requires that

s/he is physically present during the entire procedure. Example: ‘I was present for the entire procedure.

If > 5 Minutes

Example: “I was present for the entire (or key and critical portions) of the

procedure and immediately available.”

58

TP Guidelines for Procedures

3

• RADIOLOGY AND OTHER DIAGNOSTIC TESTS • General Rule: The Teaching Physician may bill for the interpretation of diagnostic

Radiology and other diagnostic tests if the interpretation is performed or reviewed by the Teaching Physician with modifier 26 in the hospital setting.

• Teaching Physician Documentation Requirements: • Teaching Physician prepares and documents the interpretation report. • OR • Resident prepares and documents the interpretation report • The Teaching Physician must document/dictate: “I personally reviewed the

film/recording/specimen/images and the resident’s findings and agree with the final report”.

• A countersignature by the Teaching Physician to the resident’s interpretation is not sufficient documentation.

59

Diagnostic Procedures

3

An Optometrist Can Be The Ordering & Treating Physician

• The CPT descriptions of documentation requirements for many

ophthalmic diagnostic tests include the phrase, ". • . . with interpretation and report." Once the appropriate individual

has performed the test, you must document your interpretation of the results somewhere in the medical records. This doesn't have to be anything elaborate.

• It may merely be a brief phrase indicating if a test is "normal," "stable from a previous test" or "mild superior arcuate defect."

60

Orders” Are Required For Any Diagnostic Procedure With a TC / 26 Modifier

3

• TEACHING PHYSICIANS WHO SEEK REIMBURSEMENT FOR

OVERSIGHT OF PATIENT CARE BY A RESIDENT MUST PERSONALLY SUPERVISE ALL SERVICES PERFORMED BY THE RESIDENT.

• PERSONAL SUPERVISION PURSUANT TO RULE 59G-1.010(276), F.C.A, MEANS THAT THE SERVICES ARE FURNISHED WHILE THE SUPERVISING PRACTITIONER IS IN THE BUILDING AND THAT THE SUPERVISING PRACTITIONER SIGNS AND DATES THE MEDICAL RECORDS (CHART) WITHIN 24 HOURS OF THE PROVISION OF THE SERVICE.

61

Florida Medicaid Teaching Physician Guidelines

3

Top Ten Compliance Issues For Documenting in EMR

62

3

CMS IS WATCHING EMR DOCUMENTATION

Once you sign your note, YOU ARE RESPONSIBLE

FOR ITS CONTENT

Documentation in EMR

63

3 3

• Every exam component . . .

• Every time you copy forward Family/Social History . . .

• Every HPI and ROS item you document means YOU PERFORMED THEM ON THAT VISIT . . .

• If you document something you did not do . . .

YOU ARE PUTTING YOURSELF AND THE INSTITUTION AT GREAT RISK!

Documentation in EMR

64

3 3

Top Ten Compliance Rules for EMR

65

1. Use “Copy Forward” with caution • Each visit is unique

• Cloned documentation is very obvious to auditors

• If you bring a note forward it MUST reflect the activity

for the CURRENT VISIT with appropriate editing

• Strongly advise NOT copying forward HPI, Exam, and complete Assessment/Plan

NOTE 06/05/12

NOTE 06/26/12

NOTE 08/06/12

HPI States: “She had a metastatic evaluation on Friday and we will review that together today”

HPI States: “She had a metastatic evaluation on Friday and we will review that together today.” “Here for 2nd neoadj chemo for bilat breast cancer”

HPI States: “She had a metastatic evaluation on Friday and we will review that together today.” “Here for 4th neoadj chemo for bilat breast cancer”

66

3 3

Top Ten Compliance Rules for EMR

67

2. Don’t dump irrelevant information into your note

• (“the 10-page follow-up note”)

• Be judicious with “Auto populate” • Consider Smart Templates instead • Marking “Reviewed” for PFSHx or labs is OK from

Compliance standpoint (as long as you did it!)

3 3

Top Ten Compliance Rules for EMR

68

3. Never copy ANYTHING from one patient’s record into another patient’s note

• Self-explanatory

3 3

Top Ten Compliance Rules for EMR

69

4. Only Past/Family/Social History and Review of Systems may be used from a medical student or nurse’s note

• Student or nurse may start the note • Provider (resident or attending) • must document HPI, Exam, and • Assessment/Plan

3 3

Top Ten Compliance Rules for EMR

70

5. Never copy documentation from another provider without clearly identifying the original author

• Can be considered a false claim

• Not always easy to do – better to avoid

3 3

Top Ten Compliance Rules for EMR

71

6. Utilize Approved Attestations for resident/fellow/mid-level provider notes

• Important that both providers are identified in the note

• “Auto-Text” makes this a 2-click process

3 3

Top Ten Compliance Rules for EMR

72

7. Be careful with pre-populated “No” or “Negative” templates

• Cautious with ROS and Exam

• Macros, Check-boxes, or Free Text are safer and more

individualized

3 3

Top Ten Compliance Rules for EMR

73

8. Authenticate all documentation and orders per policy

• 48 hours for verbal orders

• 30 days for signed documentation

3 3

Top Ten Compliance Rules for EMR

74

9. Link diagnosis to each test ordered (lab, imaging, cardiographics, referral)

• Demonstrates Medical Necessity

• Know your covered diagnoses for your common labs

3 3

Top Ten Compliance Rules for EMR

75

10. Individualize every note with a focus on the HPI and Medical Decision Making

• Results is correct coding with the focus of an E/M

selection on medical necessity

3

Redemption Tips for Copy and Paste

Physicians

76

3 3

Copy/Paste Philosophy:

Your note should reflect the reality of the visit for that day

77

3 3

• Don’t say Today, Tomorrow, or Yesterday

• Write specific dates, i.e., “ID Consult recommends ceftriaxone through 9/3” , instead of “six more days”, which could be carried forward inaccurately

• “Heparin stopped 6/20 due to bleeding” will always be better than “Heparin stopped yesterday”, which can be carried forward in error

Use Specific Dates

78

3 3

• “Neuro status remains stable, will discontinue neuro checks” can be copied forward in error

• Better – “Neuro checks stopped on 2/24”

• “Added heparin on 4/26” – uses past tense and specific date for better accuracy

Use Past Tense

79

3 3

• Avoid personal pronouns

• “I discussed code status with Ms. Smith and she requested to be DNR” could be copied forward by someone else

• “Code status discussed with Ms. Smith and she requested to be DNR” will always be acceptable and true

Avoid the use of "I”

80

3 3

• Progressive cumulative daily HPIs become unreadable and cumbersome

• Temptation exists to add no new information

• If a previous HPI is needed, it is easily found in the EMR on a past note

Delete HPI every day

81

3 3

DO NOT COPY FORWARD REVIEW OF SYSTEMS!

• This leads to contradictions and inconsistency, and danger of documenting something you didn’t do

• HPI – “Patient reports nausea this morning” • Templated ROS same day “No nausea, no vomiting”

Delete the prior Review of Systems

82

3 3

• Always better to document “fresh” exam every day

• If copied forward or templated, review the exam closely and make corrections to items you did not perform

• Credibility is questioned when ear exam is documented every day, or when amputee has “2+ pulses in bilateral lower extremities”

Document the Exam ACTUALLY PERFORMED

83

3 3

• These already exist in the EMR

• Summarize in the Assessment/Plan

• These can create unnecessary volumes of pages in notes each day

• Labs and imaging reports are not necessary for billing

Avoid Routine Daily Labs and Vitals in each note

84

3 3

Instead, put specific date requested:

• “Cardiology consult requested 3/22 at 4pm”

• This provides a legal safeguard in case of a poor outcome, as well as being accurate

• “Pending” can be copied forward for days in error

Do Not Use “Pending” for Consult Requests

85

3 3

• Copy/Paste can be a valuable tool for efficiency when used correctly

• There are major Compliance risks when used inappropriately, including potential fraud and abuse allegations, denial of hospital days, and adverse patient outcomes

• Make sure your note reflects the reality and accuracy of the service each day

SUMMARY

86

3

87

3

CASE SAMPLES

88

3 3

HIPAA, HITECH, PRIVACY AND SECURITY • HIPAA, HITECH, Privacy & Security Health Insurance Portability and Accountability Act – HIPAA – Protect the privacy of a patient’s personal health information – Access information for business purposes only and only the records you need to complete your work. – Notify Office of HIPAA Privacy and Security at 305-243-5000 if you become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords. – PHI is protected even after a patient’s death!!! • Never share your password with anyone and no one use someone else’s password for any

reason, ever –even if instructed to do so. If asked to share a password, report immediately. If you haven’t completed the HIPAA Privacy & Security Awareness on-line CBL module, please do so as soon as possible by going to: http://www.miami.edu/index.php/professional_development__training_office/learning/ulearn/

89

3 3

HIPAA, HITECH, PRIVACY AND SECURITY • HIPAA, HITECH, Privacy & Security • Several breaches were discovered at the University of Miami, one of which has resulted in • a class action suit. As a result, “Fair Warning” was implemented. • What is Fair Warning? • • Fair Warning is a system that protects patient privacy in the Electronic Health Record • by detecting patterns of violations of HIPAA rules, based on pre-determined analytics. • • Fair Warning protects against identity theft, fraud and other crimes that compromise • patient confidentiality and protects the institution against legal actions. • • Fair Warning is an initiative intended to reduce the cost and complexity of HIPAA • auditing. • UHealth has policies and procedures that serve to protect patient information (PHI) in • oral, written, and electronic form. These are available on the Office of HIPAA Privacy & • Security website: http://www.med.miami.edu/hipaa

90

3

Available Resources at University of Miami, UHealth and the Miller School of Medicine

• If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact:

• Gemma Romillo, Assistant Vice President of Clinical Billing Compliance and HIPAA Privacy; or

• Iliana De La Cruz, RMC, Director Office of Billing Compliance • Phone: (305) 243-5842 • Officeofbillingcompliance@med.miami.edu

• Also available is The University’s fraud and compliance hotline via the web at www.canewatch.ethicspoint.com or toll-free at 877-415-4357 (24hours a day, seven days a week).

• Office of billing Compliance website: www.obc.med.miami.edu

91