www.doctors-management.com 2014 © DoctorsManagement

CODING

CPT 2015: Widespread changes coming to many specialties 1

ACCOUNTING

Year-end tax planning for 2014: Mitigation strategies 6

UNDERSTANDING YOUR RISK

Effectively using corrective action plans 7

COMPLIANCE

Corrective action plan template for split/shared services 9

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Vol. 2, Issue 8

The Business of MedicineThe Business of MedicineLeave the business of medicine to us

(continued on pg. 2)

CO D I N G

CPT 2015: Widespread changes coming to many specialties

In the new year, we’ll face a multitude of changes across several specialties. Overall, 2015 will bring us 266 new codes, 147 deleted codes, and 129 revised codes.

Gastroenterology, cardiology and radiation oncology will see changes to some of their most frequently reported procedures, including colonoscopies, defibrillator services, and treatment planning. The Evaluation & Management (E/M) section will see new codes to report Chronic Care Management (CCM) and Advance Care Planning. We’ll cover each section in detail below.

E/MNew codes were created for 2015 for CCM used for reporting the services performed by the physician and their staff to address the needs of patients with multiple chronic conditions. Per CPT®: “Patients who receive chronic care management services have two or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline. Code 99490 is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities.”

These services will be reported with CPT code 99490.

CPT has also created a code for Complex Chronic Care Management, codes 99487 (…60 minutes) and add-on code 99489 (…each additional 30 minutes). The same criteria for CCM is required, as well as:

• Establishment or substantial revision of a comprehensive care plan;

The Business of Medicine, Vol. 2, Issue 8

• Medical, functional and/or psychosocial problems requiring medical decision making of moderate or high complexity; and,

• Clinical staff care management series for at least 60 minutes, under the direction of a physician or other qualified health care professional.

All of the codes within the chronic care group must satisfy their time requirements in full. This means that standard CPT time rules, which allow you to bill a code when you have exceeded 50% of its required time, don’t apply to CCM.

Another new E/M service in 2015 is Advance Care Planning, which can be billed with codes 99497 (…first 30 minutes) and add-on code 99488 (each additional 30 minutes). CPT describes these codes as an “explanation and discussion of advanced directives such as standard forms (with completion of forms, when performed) by the physician with the patient, family member(s), and/or surrogate.”

MusculoskeletalNew codes were added in the musculoskeletal section for arthrocentesis with ultrasound. Codes 20604, 20605 and 20611 were added to report an arthrocentesis, injection or aspiration within the small/intermediate/large joint utilizing ultrasound guidance. These codes require a permanent record of the ultrasound images to be maintained in the health record.

GastroenterologyWithin the gastroenterology section, we see a large editorial change that affects dozens of codes. CPT has replaced the phrase “with or without collection of specimen(s)” with the new phrase “including collection of specimen(s) by brushing or washing when performed.”

Several codes within the CPT section for colonoscopies were revised for 2015. CMS hasn’t valued the changed codes, and instead created G-codes to be reported for 2015.

• If the code has not changed from 2014 to 2015

» Physicians report the CPT code

» CMS fees based on 2014 values

• If the code has changed from 2014 to 2015

» Physicians report the G code

» CMS fees based on the 2014 values

• If the code is new for 2015, then:

» Physicians report the CPT code

» Not valued by CMS

A list of the new G-codes can be seen in the table below.

2014 CPT2015

HCPCSCode description

44383 G6018Ileoscopy, through stoma, with transendoscopic stent placement

44393 G6019Colonoscopy through stoma; with ablation of tumor(s) or other lesions

44397 G6020Colonoscopy through stoma; with transendoscopic stent placement

44799 G6021 Unlisted procedure, intestine

45339 G6022Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s) or other lesion(s)

45345 G6023Sigmoidoscopy, flexible; with transendoscopic stent placement

45383 G6024Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor

45387 G6025Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement

0226T G6026Anoscopy, high resolution (HRA) … with brushing or washing when performed

0227T G6027Anoscopy, high resolution (HRA) … with biopsy(ies)

Source: AMA CPT© and RBRVS 2015 Annual Symposium

These new codes will add a layer of complexity when coding and billing for scope procedures.

Medicare also worked towards a new screening code, G0464 for the Cologuard test. G0464: Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3).

Spine surgeryPercutaneous vertebroplasty codes were deleted and new codes have been put into place. These new codes now include bone biopsy if performed, moderate sedation, and any imaging required to perform the procedure.

Old code New code Code description

22520 22510Perc vertebroplasty, 1 vertebral body, unilateral or bilateral injection; thoracic

22521 22511Perc vertebroplasty, 1 vertebral body, unilateral or bilateral injection; lumbar

2

2014 © DoctorsManagement 3

Old code New code Code description

22522 22512+each additional thoracic or lumbar vert body

22523 22513Perc vertebroplasty, 1 vertebral body, unilateral or bilateral cannulation; thoracic

22524 22514Perc vertebroplasty, 1 vertebral body, unilateral or bilateral cannulation; lumbar

22525 22515+each additional thoracic or lumbar vert body

Source: AMA CPT© and RBRVS 2015 Annual Symposium

Lab codesWithin the laboratory section, you’ll see several deleted and revised codes as CPT has moved from a qualitative/quantitative method of coding to a new system. This new system is defined by “presumptive” or “definitive” testing.

Per CPT, this change is being made due to:

• Advances in medicine, number and type of materials tested, growth in specialty practices that directly deal with drug testing (such as Pain Medicine)

• Allows identification of quantitative testing of multiple analytes within a single procedure

• Methods for reporting analytes now more closely reflect the effort needed to complete current methods for testing

OphthalmologyUtilization showed that a high number of aqueous shunt procedures for glaucoma were done in conjunction with a scleral patch graft. CPT has now revised existing code 66180 to include the patch graft, and added new code 66179 for an aqueous shunt procedure without a graft. Shunt revision code 66185 was also revised to include the graft, while new code 66184 is used to report a revision procedure to an aqueous shunt not requiring a scleral graft.

CardiologyEditorial changes were made to defibrillator codes, changing the terminology from “pacing cardioverter defibrillator” to “implantable defibrillator.” This was done mainly to accommodate the new codes in this section for subcutaneous defibrillators:

• 33270. Insertion/replacement of subcutaneous defibrillator system, pulse generator plus lead

The Business of Medicine, Vol. 2, Issue 84

• 33271. Insertion of subcutaneous defibrillator electrode

• 33272. Removal of subcutaneous defibrillator electrode

• 33273. Repositioning of previous implanted electrode

RadiologyBreast ultrasound code 76645 has been deleted and in its place we have two new codes:

• 76641 represents a complete ultrasound examination of the breast, including examination of all four quadrants of the breast and the retroareolar region

• 76642 consists of a focused ultrasound examination of the breast, limited to the

assessment of one or more quadrants but not all of the elements of the complete examination

New codes were created to report breast tomosynthesis procedures. This procedure creates a 3D image of the breast using X-rays.

• 77061. Digital breast tomosynthesis; unilateral

• 77062. Bilateral

• +77063. Screening digital breast tomosynthesis, bilateral, list separately in addition to code for primary procedure

CMS will recognize code 77063 to be reported when tomosynthesis is used in additional to 2D mammography, as this service does not have an equivalent 2014 code. CMS created G2079 (Diagnostic digital breast tomosynthesis, unilateral or bilateral – list separately in addition to G0204 or G0206).

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Plastic surgery group, Worcester MA Practice management

Internal medicine group, Melbourne FL Practice management

OB/GYN, Chattanooga TN Practice startup and advisory

Dermatology group, Chapel Hill NC Credentialing services

Medical device manufacturer, Gaithersburg MD Billing and credentialing services

Hematology/oncology group, Palm Beach FL Billing and credentialing services

Group practice, Morgantown NC Credentialing services

Plastic surgery group, Ft. Lauderdale FL Practice startup

Pulmonology group, Palm Harbor FL HR consulting

Optometry/ophthalmology group, Jacksonville FL HR consulting

Dermatology group, Lexington KY Power buying services

Pediatric group, Gainesville FL Power buying services

Integrated health system, Morristown NJ Power buying services

Pediatric group, Alexandria LA Power buying services

Pediatric group, Pittsfield MA Power buying services

Sleep and pulmonary care group, Decatur AL Practice assessment

Neurology group, Tampa FL Practice startup pro forma

Orthopedic and spine practice, York PA Audit and education

Podiatry group, Charlotte NC OSHA/HIPAA audit and training

ENT practice, Louisville KY OSHA/HIPAA audit and training

Orthopedic group practice, Leesville LA Credentialing services

2014 © DoctorsManagement 5

Radiation oncologySeveral codes within this code family have been changed to stop distinguishing between the level of megaelectronvolts (MeV) delivered. Revised codes for 2015 simply state greater than or equal to 1 MeV (shown in CPT as ≥ 1 MeV).

Deleted codes (9) Remaining but modified codes (3)

77403

77404

77406

77402, radiation treatment delivery, ≥ MeV; simple

77408

77409

77411

77407, radiation treatment delivery, ≥ MeV; intermediate

77413

77414

77416

77412, radiation treatment delivery, ≥ MeV; complex

Source: AMA CPT© and RBRVS 2015 Annual Symposium

Multiple guidance codes were removed for 2015 and replaced with a single code that isn’t dependent on the modality.

Deleted codes (3) New codes (1)

77421, stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

77387, guidance for localization of target volume for delivery of radiation treatment, includes intra-fraction tracking when performed

76950, ultrasonic guidance for placement of radiation therapy fields

0197T, intra-fraction localization and tracking of target or patient motion during delivery or radiation therapy

Source: AMA CPT© and RBRVS 2015 Annual Symposium

We also received two new codes for intensity modulated radiation treatment delivery (IMRT):

• 77385. IMRT delivery, includes guidance and tracking when performed; simple

• 77386. IMRT delivery, includes guidance and tracking when performed; complex

These codes replace 2014 code 77418 and Category III code 0073T.

Family practice/pediatricsNew and revised codes are located within the immunization/vaccination section of CPT:

• 90651. Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58 (HPV) nonavalant, 3 dose schedule for intramuscular use)

• 90630. Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use

• 90654. Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use

Code 96110 has been revised for 2015 to clarify this code is only reported for a developmental screening, not behavioral assessments. New code 96127 was established for behavioral assessments.

• 96110. Developmental screening (e.g., developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument

• 96127 Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument (For developmental screening, use 96110)

CPT also created a new code for use in 2015 for applying fluoride varnish to teeth.

• 99188. Application of topical fluoride varnish by a physician or other qualified health care professional

This code can only be reported when the physician or other qualified health care professional (such as an NPP) performed this service, not when ancillary/nursing staff apply.

CMS has also stated this service is not a covered benefit.

References:

• AMA 2015 CPT®Professional

• AMA CPT ® Changes 2015: An Insider’s View

• AMA CPT® and RBRVS 2015 Annual Symposium

• CMS 2015 Physician Fee Schedule

— Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC (rtyler@drsmgmt.com). The author is a Senior Consultant at DoctorsManagement and a NAMAS Instructor.

The Business of Medicine, Vol. 2, Issue 86

ACCO U NTI N G

Year-end tax planning for 2014: Mitigation strategies

This is the second of a two-part series relating to year-end tax planning for businesses and individuals. In our last

article, which appeared in our November newsletter, we discussed the tax law changes that affect 2014, including the following topics:

• Marginal tax rate increases

• Net investment income tax and additional Medicare tax

• Increased capital gains rate

• Phase-out of exemptions and itemized deductions

• Expired Section 179 and bonus depreciation

• Health insurance mandate

In this article, we will focus on year-end planning and tax tips that could help mitigate the impact of these

changes. The first strategy is to defer income to 2015. By simply moving income from 2014 to 2015, you will give yourself an extra year to pay the tax. The next strategy is accelerating deductions. By taking deductions in 2014 instead of 2015, you will delay some of your tax burden another year.

Deferring incomeBy shifting income from 2014 to 2015 or even later, a taxpayer is able to delay payment of the tax on that income. Below are some options to do this:

401(k)/retirement plan. If you are covered by a retirement plan, make sure that you have deferred the maximum amount in to this plan. In 2014, the maximum deferral in to a 401(k) is $17,500. If you are 50 or over, an additional $5,500 can be deferred for a total of $23,000. Please note that these amounts must be deferred before Dec. 31, 2014. If the plan has a safe harbor or profit-sharing component, an additional amount can be contributed but the total cannot exceed $52,000. The profit sharing and/or safe harbor portion are not due until the due date of the business tax return which should provide some more time to fund the plan for those that need it. If your practice does not have a 401(k), it is probably too late to set one up for 2014 but you still have other options. A SEP IRA allows for up to $52,000 in contributions and can be set up all the way until the due date of the tax return (including extensions).

Year-end bonus. This strategy is geared toward employees and doesn’t work as well for those who are self-employed. However, if you are an employee and are due a year-end bonus, consider taking that bonus in January instead of December. Of course, your employer would have to allow you to do this, and not all may do so. If you can do this, the income will move from 2014 to 2015, giving you more time to pay the tax due.

Capital gains. When a capital asset is sold (stocks, bonds, and/or property) the taxable gain is calculated based on the difference between the purchase price and the sale price. If you have both losses and gains, they are offset and the net is taxed. As the year-end approaches, consider harvesting some of those losses to offset any gains that you may have had throughout the year. If you have a loss carryover or have a loss created in 2014, consider selling some of the assets that have a gain to

2014 © DoctorsManagement 7

offset the loss. If you still think the stock is a good investment, consider buying it back in 30 days. Otherwise, the loss will not be allowed because of wash-sale rules. If you do not have any losses to offset gains, consider selling any gains in January instead of December. This will delay the tax due for another year. If the capital asset is a business or real property, consider an installment sale. In an installment sale, payments are received over a number of years. Taxes are only paid

when the funds are received instead of all proceeds being taxed in the year of sale.

Accelerating deductionsThe law allows for some deductions to be taken on the year of payment and not necessarily when they are due or accrued. Thus, by moving payments up a few weeks, you might substantially reduce your taxable income.

State income taxes. Do you live in state that has an income tax? If so, you are probably making quarterly estimated payments to the state. The last of these payments is due on Jan. 15, 2015. However, if you make that payment on Dec. 31, 2014, instead of Jan. 2015, you may be able to deduct the payment on your 2014 taxes. small timing change can make a big difference on your 2014 taxable income.

In my daily duties as a Compliance Officer for both large and small practices, I often see not just areas of possible risk, but situ-ations where accusa-tions of intentional

impropriety are raised.

When this happens, I would first advise you to seek the guidance of legal counsel so that potential issues are placed under attorney-client privilege, which will en-sure you get the full protection afforded under state and federal law.

If the accusations do in fact point to problems that need addressing, you may want to implement a corrective action plan. What is being provided here is a template for a plan that can be adapted to any issue. Remember, for any plan to be effective, it needs to be followed consistently until the issues are corrected and clean claims are sub-mitted moving forward.

The template can be found on a separate full page (see pg. 9). For the purposes of this template, we’ll take a

look at a fictional practice that has a problem with following split/shared billing rules, which were created by Medicare for situations where both a physician and a non-physician practitioner (NPP) share an inpatient encounter with a patient.

Below are a few key issues that arise with split/shared visits, and these are details that could be used along with the tem-plate to address this topic.

• Documentation requirements not met. To bill split/shared services under a physician PTAN/NPI, and thus earn payment at 100% of the Medicare fee schedule rate, the note should document which parts of the service were performed by whom.

Example: The addendum below would not satisfy the requirements of Medi-care’s Split/Shared Services rule.

“Addendum by _______________ on 22 November 2014 09:38 (Verified)

Patient seen and examined on day of discharge. DC diagnosis and hos-pital course as outlined above. DC plan as outlined above.”

Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the parts that he or she per-sonally performed. When the supporting documentation doesn’t demonstrate that the physician “performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service” as the service performed by the NPP, a service billed under the physician’s identifier will be denied.

• Common documentation phras-es that fail to support split/shared. It is of particular importance to remember that notes documented by the NPP for E/M services per-formed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit. Additionally, “incident-to” guidelines don’t apply to services in an inpatient setting. In this situation, the service should be billed under the NPP’s provider number, and would be reimbursed at the established rate for that provider.

Effectively using corrective action plans

UNDERSTANDING YOUR RISK: A column by Sean M. Weiss

(continued on pg. 8)

The Business of Medicine, Vol. 2, Issue 88

Property taxes. The same is true for property taxes. Many taxpayers have their property taxes taken out of the mortgage payment in escrow. However, if you pay your property taxes personally, make sure that they are all paid by Dec. 31, 2014, which will allow you to deduct the payments on your 2014 tax return and not 2015.

Mortgage payments. Consider paying your January mortgage payment in December. This would allow for the deduction

of interest to be taken in 2014 and not 2015. The deduction is only for the interest on that payment; extra payments toward principal are not deductible.

Health Savings Account. If you have a high deductible health insurance plan, make sure to fully fund your HSA. The maximum amount for 2014 is $6,550 for a family with an additional $1,000 available for those aged 55 and over. The IRS gives taxpayers until April 15, 2015 to make these contributions.

Charitable contributions. Charitable contributions are deductible in the year they are paid. Therefore, if you are considering a large contribution, make it in December 2014 instead of early 2015.

As always, if you have any questions, please feel free to contact us at 800-635-4040.

— Blake King, CPC, MAcc, CVA (tbking@drsmgmt.com). The author is a Partner and Director of Accounting at DoctorsManagement.

With the IOM requirements in mind, the following are common examples of physician documentation which would not be adequate to support a split/shared visit:

• “I have personally seen and examined the patient inde-pendently, reviewed the PA’s Hx, exam and MDM and agree with the assessment and plan as written” signed by the physician

• “Patient seen” signed by the physician

• “Seen and examined” signed by the physician

• “Seen and examined and agree with above (or agree with plan)” signed by the physician

• “As above” signed by the physician

• Documentation by the NPP stating “The patient was seen and examined by myself and Dr. X., who agrees with the plan” with a co-sign of the note by Dr. X

• No comment at all by the phy-sician, or only a physician sig-nature at the end of the note

ConclusionPlease remember that for a split-shared visit, there must be docu-mentation of the face-to-face por-tion of the E/M encounter between the patient and the physician. The medical record should also clearly identify and distinguish between the parts of the E/M service which were personally provided by the physi-cian, and those which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP’s pro-vider number per CMS IOM Publica-tion 100-04, Chapter 12, Section 3.

Below is an example of what we would want to see in a note by a physician:

“History: Patient is seen this morning at bedside in follow-up for possible obstructed bowel and appears in no apparent distress. Pt denies any further nausea or vomiting as well as total reso-lution to diarrhea. Pt has asked to have

the NG tube removed which we will proceed with today.

Exam: On physical exam the patient is alert and oriented x3. The patient’s belly is soft and non-tender with no re-bounding or guarding. There is positive bowel sounds. Respiratory is clear to auscultation. Cardiovascular is regular rate and rhythm. There is no edema, clubbing or cyanosis.

Assessment and Plan: I have met with and agree to the treatment plan as out-lined by Jon Doe, NP. However, I want to add Omeprazole 20mg in the AM and 20mg in the PM for a period of 60 days and then reduce to 1 in the morning to see if this will resolve the GERD.”

— Sean M. Weiss, CPC, CPC-P, CPMA, CCP-P, ACS-EM (sweiss@drsmgmt.com). The author is a Partner, Vice President and Chief Compliance Of-ficer for DoctorsManagement. His col-umn appears monthly in The Business of Medicine newsletter. Questions regarding the law in your state should be directed to your company attorney. For questions on this topic, email Sean at sweiss@drsmgmt.com.

Effectively using corrective action plans (cont. from pg. 7)

2014 © DoctorsManagement 9

CORRECTIVE ACTION PLAN TEMPLATE FOR SPLIT/SHARED SERVICES

I. ISSUE / PROBLEM DEFINITION Patients seen and evaluated in the inpatient setting of the hospitals are done so in conjunction by the non-physician practitioner and the physician on a given date of service. These are referred to as split/shared services by the Centers for Medicare and Medicaid Services. Documentation requirements to bill these services under a physician PTAN/NPI are specific and without meeting these guidelines services are required to be billed under the non-physician practitioner’s number.

An outside review was performed by DoctorsManagement, LLC to validate the concerns on _________, 2014 by _____________________________. Of concern _____ dates of service were reviewed and only _____ supported the billing of the service as a “True” Split/Shared Service. This left ______ dates of services as inappropriately documented leading to a ________ (___) percent accuracy rate.

II. ROOT CAUSE EVALUATION Based on an internal review of documentation conducted, concerns were raised as to whether or not the services were being performed and documented in accordance to the CMS documentation requirements as outlined in Chapter 12, Section 30.6.1(B), as an E/M service, “...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.” Additionally, IOM Publication 100-04, Chapter 12, Section 30.6.13 (H) states that, “A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service.”

III. ACTION STEPS ______________, Compliance Officer: Will provide education and training back to Medical Practice USA executives, coders, and providers to ensure complete understanding of Medicare’s Split/Shared Services requirements, which will correct the current issue and prevent further errors in documentation and billing moving forward. A template for provider documentation will be created to include proper language for attesting to a NP or PA’s documentation in addition to elements of the history, examination and medical decision making required to support the various levels of documentation billed. This will be a collaborative process and upon implementation of the template AHS will review and make recommendations for improvement or will sign-off on the template as acceptable.

It is recommended the compliance officer or compliance team evaluate potential retrospective risk and address with Medical Practice USA Executives.

IV. IMPROVEMENT BENCHMARK(S) AND TIMEFRAME 1. A re-review of inpatient documentation is recommended within the next 60 days from the date of training to ensure compliance with the guidelines. At this time any new questions or concerns that may arise from this change in process can be addressed. Failure to achieve these improvement benchmarks could result in additional corrective action.

This Corrective Action Plan is effective 11/22/2014 through 12/31/2014.

V. CERTIFICATION The undersigned have read this Corrective Action Plan and agree to its terms.

___________________________________________________ ____________________VP, Medical Practice USA Date

___________________________________________________ ____________________ YOUR NAME (Compliance Officer) Date

®

Sample template prepared by