Another urban myth about coding
Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved. He asked me if this was true.
As I have done with other callers asking the same question, I assured him that this was incorrect information. Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter). For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. In no case does CPT state that medical decision making, by itself, determines the level of E/M service.
Medicare policy supports this interpretation. Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.” That content includes the history and examination.
This particular urban coding myth grows out of confusion between medical decision making and medical necessity. As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance. In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service.
So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.
Posted at 04:47PM Apr 27, 2009 by Kent Moore | Comments[0]
Pay for performance: It's not just for doctors anymore
It's a different interpretation of pay for performance, but the concept does apply to Medicare's Recovery Audit Contractors (RAC) program. Physicians in California and other states involved in the demonstration program may already understand the ramifications of this effort to recover improper Medicare payments. Now that the permanent program for RACs is gearing up across the country, it's important for all physicians to understand how it works.
The RAC program is different from Medicare safeguard audits like Comprehensive Error Rate Testing (CERT) that focus on identifying error rates for the Medicare payment contractors or postpayment review audits performed by individual carriers. RACs contract with the Centers for Medicare & Medicaid Services to perform post-payment reviews of Medicare claims to find overpayments and underpayments in return for a percentage (from 9 percent to 12.5 percent) of the amounts recovered. Put simply, they eat only what they kill. According to an evaluation of the three-year demonstration program, RACs returned $693.6 million to the Medicare trust funds, after subtracting the dollars in refunded underpayments, overpayments overturned on appeal, and operating costs for the program.
The RAC has two methods of uncovering improper payments - using computer software to analyze claims and auditing medical records. Hospital claims will likely continue to be a focus of their efforts, as was the case in the RAC demonstration program. However, hospitals have mobilized to defend themselves against RAC recoveries. At this time, physicians should not be overly concerned about being targeted but must not expect to be exempt from the program.
You should be aware of your rights in relation to records requests and refunds and how you might avoid some problems. If your practice does not have policies and processes in place to be sure that records sent in response to a payer/auditor request are appropriately screened for accurate dates of service and completeness and returned within the required time frame, I hope you'll schedule a few minutes to discuss the importance of this and establish a standard for your practice. It could save you money and headaches.
The AAFP has joined others in asking CMS to make changes to the program to lessen the burden and the risk to physicians. The AAFP has also put together an online guide to answer questions about the RACs and provide some tips that may help lessen the burden if an RAC does contact you.
It's a shame that honest physicians need to concern themselves with programs like this one, but here's hoping that the contractors do a good job of finding and stopping those few who create most of the concerns about fraud and abuse. They are out there, and now there are bounty hunters looking for them.
Have you had any experience with an RAC? Has the RAC contractor for your area provided any education to physicians? If you have tips that may help your fellow physicians, I hope you will share them.
Posted at 04:17PM Apr 03, 2009 by Cindy Hughes | Comments[0]
April fools
Effective April 1, 2009, UnitedHealthcare (UHC) is implementing a new fee schedule that will impact approximately 70,000 physicians nationwide. The effective date of this new fee schedule is not the only thing funny about it. You’ll laugh until you cry.
Recipients of the new fee schedule were previously on what UHC termed a “progressive” fee schedule. (Admittedly, the idea of any health plan, let alone UHC, having a “progressive” fee schedule is funny in and of itself. But, I digress.) That fee schedule featured a fixed conversion factor and relative value units (RVUs) that changed annually based on changes in RVUs in the Medicare physician fee schedule.
The new fee schedule is what UHC calls a “stated year fee schedule.” Under this fee schedule, the physicians’ fees will be based on their existing conversion factors and 2008 Medicare RVUs and non-RVU based fees, and these values will not change on an annual basis.
In essence, affected physicians will have their fees from UHC frozen at their current rates. (No, this is not an April Fools Day joke.)
When asked about this fact, UHC staff responded that network physicians always have the right to initiate negotiations with UHC regarding their fees. So, in effect, the fees are only frozen until the physicians negotiate an increase with UHC or the Cubs win the World Series, whichever comes first.
UHC's rationale for the change is that “recent congressional activity affecting Medicare payment to physicians has introduced new complexity to some of our existing contractual arrangements.” The activity in question is Congress’ mandate that Medicare quit implementing budget neutrality adjustments by simply adjusting work RVUs. UHC had heretofore taken advantage of the adjusted Medicare RVUs, which were lower than the unadjusted RVUs mandated by Congress for 2009. Because of the congressional mandate, continuing to use Medicare RVUs and a fixed conversion factor as the basis for its “progressive” fee schedule would have meant a significant increase in expenditures for UHC. Unable to handle this “new complexity” (“What? We have to pay more?!?”) and in an effort to “stabilize” the methodology for its physicians, UHC decided to change its fee schedules.
“Stability through change.” It’s the new oxymoron of our times.
In any case, UHC has assured affected physicians that they will “see no difference with this new fee schedule and your current reimbursement.” Of course they won’t, because UHC is freezing their reimbursements at the 2008 level. Now, if only they could freeze physicians’ cost of practice at the same time.
Of course, one thing more foolish than UHC’s new fee schedule and its rationale would be actually accepting it.
Posted at 11:51AM Mar 27, 2009 by Kent Moore | Comments[0]
For whom the bell curve tolls
As many family physicians, coders, and billers know, if your E/M coding pattern varies significantly from the norm of other physicians in your specialty, a Medicare audit can result. But what does the norm look like? According to national data from the Centers for Medicare & Medicaid Services for 2007 (the most recent data available), it looks like this for family physicians:
As one would expect, the norm is almost a bell-shaped curve. If your coding pattern is to the right of this curve (i.e., you code a significantly greater percentage of your encounters at higher levels than the norm), you may want to review the documentation for a sample of encounters to ensure that (1) the documentation supports the level of service and (2) the level of service seems medically reasonable or appropriate.
If your coding pattern is to the left of the curve (i.e., you code a significantly greater percentage of your encounters at lower levels than the norm), you may still want to review the documentation for a sample of encounters. In this case, the rationale for doing so is to ensure that you are not routinely undercoding and leaving money on the exam table in the process. If you're not sure of your coding pattern, you can download an Excel spreadsheet from the FPM Toolbox that will help you calculate it.
In the end, it is not important that you conform to the norm. Rather, it is important that you know where you stand relative to the norm and be able to explain and defend your position, if called upon to do so.
Posted at 04:43PM Mar 03, 2009 by Kent Moore | Comments[2]
ICD-10: Y2K all over again?
People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.
Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.
Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.
Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:
1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.
2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).
3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.
Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.
Posted at 03:50PM Jan 29, 2009 by Cindy Hughes | Comments[1]
The future of diagnosis coding
The Centers for Medicare & Medicaid Services (CMS) announced the future of diagnosis coding for physicians last week. Specifically, on Jan. 16, CMS published a final rule specifying that by
The good news is that you have almost five years to get ready, which is two years longer than CMS originally proposed. The bad news is that you will still have to make systems changes and train yourself and your staff to use the new codes.
In the meantime, you and your practice will also have to comply with an updated X12 standard, Version 5010, for certain electronic health care transactions, including claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Version 5010 accommodates the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1, the current X12 standard. The compliance deadline is
They say that “forewarned is forearmed.” Please consider yourself “forewarned” and anticipate that Family Practice Management, the
Posted at 05:15PM Jan 21, 2009 by Kent Moore | Comments[0]
Injection rejections
It’s annoying. You’ve submitted your claims for subcutaneous injections with code 90772 for a couple years now and all of a sudden, rejections! The code has been changed to 96372. Who's responsible for this disruption to your cash flow? It was the insurance companies, wasn’t it?
No. Insurance companies do have some influence on CPT code changes but really not that much. CPT code changes can be proposed by anyone who identifies a problem or gap in existing codes. Many originate from physician complaints made to specialty societies about payment policies that don’t align with CPT or current practices. All proposed changes are vetted and recommended for approval, modification or rejection by physician volunteers from each of the medical specialty societies that participates in the AMA's CPT process. Proposals are then approved, postponed or rejected by the AMA's 17-member CPT Editorial Panel. Most of the panel members are physicians nominated by their specialty organization and appointed by the AMA Board of Trustees. David Ellington, MD, of Lexington, Va., and the AAFP Board of Directors is a member of the panel. A handful of the panel members represent payers.
So what else has changed in CPT 2009 and how are you, a busy physician, supposed to care for your patients and your practice and keep up with all of this? You can look to Appendix M of your 2009 CPT book for a summary of the deleted codes and their replacements. Also, watch for an article in the January/February issue of FPM on the code changes most affecting family medicine. And finally, don’t hesitate to contact me (chughes@aafp.org) or join the AAFP e-mail discussion list for coding issues to find help with coding questions and keep up-to-date. (The discussion list is also open to non-members so that your coding and billing staff can take advantage of this free resource.)
Posted at 05:15PM Jan 14, 2009 by Cindy Hughes | Comments[1]
The future of physician payment?
The start of a new year is often a time to look ahead and try to foresee the future. As I do that this January with respect to physician payment, I see “value-based purchasing” on the horizon.
What is “value-based purchasing?” Good question. I do not have a definitive answer, but I can tell you that the folks in the Centers for Medicare & Medicaid Services (CMS) view it as something that “aligns payment more directly to the quality and efficiency of care provided by rewarding providers for their measured performance across the dimensions of quality.”
And this is not just idle musing, either. By law, the Secretary of Health and Human Services is to develop a plan to transition to a value-based purchasing program for Medicare payment for covered professional services (including physician services) and submit a report to the Congress no later than May 1, 2010. To that end, CMS held a public listening session on this topic on Dec. 9, 2008, and has released an issues paper for review and comment.
What this all means for physician payment is not yet clear. However, I can imagine a day in the not-too-distant future when Medicare and other payers rely less on “fee-for-service” and more on what we have heretofore called “pay-for-performance.” In the meantime, it may be wise to keep an eye on CMS’s plans for transitioning to “value-based purchasing” as an indicator of things to come.
Posted at 04:57PM Jan 05, 2009 by Kent Moore | Comments[0]
