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Friday, August 15, 2014

Open Payments program reopens after two-week glitch

The online database for a new federal program designed to track financial relationships between physicians and medical suppliers has reopened after a technical glitch forced officials to close it down almost two weeks ago.

Physicians will also have more time to check the database for errors.

The Centers for Medicare & Medicaid Services (CMS) announced Friday that physicians and teaching hospitals were again allowed to access the Open Payments system (formerly called the Sunshine Act). The initiative will eventually disclose financial payments or other transfers of value that pharmaceutical or medical device manufacturers and group purchasing organizations have made to individual physicians.

CMS shut down the system on Aug. 3 after discovering that some manufacturers and group purchasing organizations had mixed up records for physicians who have similar names, which allowed the physicians to see information that was not their own. The agency said it has worked to fix the problem, including making sure that all payment records are connected to a single physician and that the erroneous information is not published.

Despite the delay, and lingering concerns from some medical societies about releasing the data, CMS said it will still release the financial information to the public as scheduled on Sept. 30.

However, CMS has extended the 45-day period during which physicians who have registered with CMS can review and dispute data attributed to them. Originally scheduled to end on Aug. 27, the review and dispute period will now end on Sept. 8.

CMS asked physicians to make sure the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain, and Ownership System (PECOS) have their correct first name, last name, National Provider Identifier (NPI), and license information. CMS uses these programs to verify payments. The agency also said physicians should provide complete and accurate information when registering for Open Payments so that CMS can accurately match records reported about them by manufacturers and group purchasing organizations.

Thursday, August 14, 2014

Medicare offers ICD-10 testing opportunities

Now that the Centers for Medicare & Medicaid Services (CMS) has declared Oct. 1, 2015, as the new compliance date for switching to the ICD-10 coding system, the agency can again turn its eyes toward making sure Medicare providers are ready. The CMS has announced its approach to preparing the Medicare fee-for-service (FFS) community, focusing on four areas:

• CMS internal testing of its claims processing systems
• CMS Beta testing tools available for download
• Acknowledgement testing
• End-to-end testing

The first two areas are largely in CMS's control. But as for acknowledgement testing, physicians are welcome to submit acknowledgement test claims anytime up to Oct. 1, 2015. In addition, CMS is planning special week-long acknowledgement tests in November 2014, March 2015, and June 2015 to give submitters access to real-time help desk support and allow CMS to analyze testing data. Registration is not required for these virtual events, and physicians should contact their Medicare Administrative Contractor (MAC) for more information about acknowledgment testing.

CMS plans to offer Medicare claims submitters the opportunity to participate in end-to-end testing with MACs and the Common Electronic Data Interchange contractor in January, April, and July 2015. As planned, approximately 2,550 volunteer submitters can participate over the course of the three testing periods. CMS says that additional details about end-to-end testing will be available soon.

In the meantime, for more information, see Medicare Learning Network Matters Special Edition Article #SE1409 , “Medicare FFS ICD-10 Testing Approach.”

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, August 8, 2014

More physicians using EHR, but little information flowing between them

A new survey shows that physicians, particularly those in primary care, are continuing to adopt electronic health record systems at a rapid pace.

In fact, almost 80 percent of office-based physicians reported using some form of an electronic health record (EHR) in 2013, according to the study performed by the Centers for Disease Control and Prevention's National Center for Health Statistics and released this week in Health Affairs. Forty-eight percent of all physicians said their EHR systems could perform a series of "basic" EHR functions, such as recording medication and allergy lists, saving clinical notes, prescribing medication electronically, or viewing lab and imaging reports. That was double the adoption rate in 2009 and up 22 percent from 2012.

Primary care physicians' rate of adoption was highest with 53 percent saying they had a basic system, compared with 43 percent of physicians in other specialties.

But the survey also found that relatively few physicians are using or are capable of using their EHR systems to exchange patient care information with their fellow physicians, hospitals, or health systems, or even the patients themselves. Only 39 percent of office-based physicians said they had performed health information exchange with other providers or hospitals last year. Providers in larger practices or those owned by a hospital or academic medical center were far more likely to exchange information than small and solo practices.

Patient engagement with the EHR was also lagging as only 41 percent of physicians said they had the ability to let patients view, download, or transmit their health information online. Of those, about half said they actually used it. And while close to half of all physicians said they could exchange secure messages with patients through their EHR, two-thirds said they didn't in 2013.

Those results will continue to create concerns ahead of the deadline for complying with Stage 2 Meaningful Use requirements, which particularly stress interconnectivity and patient outreach.

A separate study that focused on EHR adoption and use by hospitals found that almost 60 percent of hospitals had adopted at least a basic EHR, but less than 6 percent were considered ready for Stage 2 Meaningful Use.

For information on how your practice can meet Stage 2 Meaningful Use requirements, see "Making Sense of Meaningful Use Stage 2: Second Wave or Tsunami?" in the January/February 2014 issue of FPM.

Tuesday, August 5, 2014

It's official: You have another year to prepare for ICD-10

Last week, the secretary of Health and Human Services (HHS) issued a final rule designating Oct. 1, 2015, as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.

That means that you and your practice have another year to prepare, and the Centers for Medicare & Medicaid Services (CMS) seems committed to doing what it can to help. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. Also, CMS has an extensive array of ICD-10 resources on its web site, including the Road to 10, a free online tool that enables small provider practices to create an ICD-10 action plan and jumpstart their transition. The AAFP also has ICD-10 resources on its web site, including a timeline to assist physicians in preparing the transition to ICD-10 and a tool to calculate how much it will cost to implement ICD-10 in your practice.

Not to be outdone, Family Practice Management has amassed a collection of articles on the topic.

Whether you seek resources from CMS, AAFP, FPM, or someone else, it is not too late and certainly not too early to get started in the transition process.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, July 22, 2014

Improve the chances of your Medicare claims for obesity counseling

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter said that documentation for obesity counseling has led to numerous instances of overpayment and other errors. Here’s what you need to know to ensure your documentation passes muster in an audit.

First, Medicare covers and pays for behavioral counseling for beneficiaries with obesity, measured as a body mass index (BMI) of 30 kg/m2 or greater. Specifically, obese Medicare beneficiaries are eligible for:

•    One face-to-face visit every week for the first month;
•    One face-to-face visit every other week for months 2-6; and
•    One face-to-face visit every month for months 7-12, if the beneficiary achieves the required weight loss.

Per Medicare, beneficiaries must be competent and alert at the time that they receive counseling, and the counseling must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Additionally, at the six-month visit, the beneficiary should receive a reassessment of obesity and a determination of the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for during months 7-12, beneficiaries must achieve documented weight loss of at least three kilograms (6.6 lbs.) during the first six months of intensive therapy.

Obesity counseling is reported with Healthcare Common Procedure Coding System (HCPCS) code G0447, “Face-to-face behavioral counseling for obesity, 15 minutes.” Medicare reviewers conducted a special study of HCPCS code G0447. Upon review, they determined that insufficient documentation caused approximately 92 percent of the improper payments. Examples of “insufficient documentation” included:

•    No physician’s signature on the encounter note
•    No documentation of the patient’s clinical condition
•    No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2
•    No documentation that after six months the beneficiary lost 6.6 pounds or 3kg
•    No documentation that obesity counseling and dietary assessment actually occurred

So, to help improve the chances that your claims for obesity counseling will stand up to Medicare scrutiny, you need to document the patient’s clinical condition and qualifying BMI. You also need to document how much weight the patient has lost at the six-month mark and the counseling and dietary assessment that occurred at each visit. Finally, don’t forget to sign the encounter note when you’re done.

Medicare covers intensive behavioral therapy for obesity per National Coverage Determination 210.12. You can learn more about this benefit and the associated rules by reading section 200 of chapter 18 in the Medicare Claims Processing Manual as well as the Medicare Learning Network Matters article on obesity counseling.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, July 16, 2014

CMS looks to add new code to track care provided off hospital grounds

If you're in a family medicine practice owned by a hospital or other health system, the recently proposed 2015 Medicare physician fee schedule offers some new reporting requirements.

The Centers for Medicare & Medicaid Services (CMS) wants to require hospitals and physicians to report a coding modifier for those services furnished in an off-campus, provider-based department.  

The modifier would be reported on both the claim form for physicians’ services and on hospital outpatient claims. CMS defines a hospital campus to be the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the CMS regional office. The new rule would apply to everything outside of that.

CMS said the information collected will help it improve its practice expense data and methodology under the physician fee schedule and more appropriately account for the different resource costs among traditional office, facility, and off-campus, provider-based settings.

The AAFP has prepared a summary of these and other changes proposed by CMS. You can access the full proposed rule  through the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, July 11, 2014

Medicare proposes paying for chronic care management

The Centers for Medicare & Medicaid Services (CMS) wants to begin reimbursing physicians for some of the unpaid care management services they provide patients with several chronic conditions.

Contained in CMS's proposed 2015 Medicare physician fee schedule, the provision would pay approximately $42 for the chronic care management (CCM) code no more than once per month per qualified patient. The payment is intended to compensate physician practices for non-face-to-face CCM services for Medicare beneficiaries who have two or more significant chronic conditions.

Under the proposal, CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Other requirements to bill Medicare for CCM services include:

• Access to care management services 24 hours a day, seven days a week, which means providing beneficiaries with a way to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

• Care management for chronic conditions, including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.

• Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

• Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after a beneficiary visit to an emergency department; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

CMS proposes that practices use an electronic health record (EHR) or other health information technology or information exchange platform to furnish the CCM services. It also says that technology solution should include an electronic care plan that is accessible to all providers within the practice, regardless of the hour of day, as well as being accessible to care team members outside of the practice. Physicians and other qualified health care professionals furnishing CCM services beginning in 2015 would be required to use an EHR certified to at least 2014 Edition certification criteria.

The AAFP has prepared a summary of this and other changes proposed by CMS.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, July 8, 2014

CMS looks to tweak Open Payments reporting for CME events

The Centers for Medicare & Medicaid Services (CMS) Open Payment initiative hasn't truly gone into effect yet and its framers already want to change it.

The Open Payment program, which tracks and discloses financial relationships between physicians and drug and device manufacturers, will begin releasing that information by the end of September. Physicians will be able later this month to review the information reported about them and report any errors.

But in the 2015 Physician Fee Schedule proposed rule announced on July 3, CMS proposed some changes to the program based on feedback from stakeholders since the original rules were introduced last year.

Chief among those changes is a proposal requiring that applicable manufacturers disclose any payments or other transfers of value made to speakers at continuing education programs.

These types of payments had been excluded under the current rules, assuming they met three criteria:

• The speaker is appearing at a program accredited or certified by the ACCME, AAFP, ADA, AMA, or AOA,
• The manufacturer does not pay the speaker directly,
• The manufacturer does not choose the speaker or provide the third-party organizer with a list of preferred speakers.

CMS said commenters have argued that limiting the exemption to speakers at events tied to just those five organizations made the reporting requirements inconsistent and appeared to give continuing education events held by those five organizations CMS's "endorsement or support."

The agency said this was an "unintended consequence" and proposed removing the exemption language in its entirety.

Open Payments already has a general exemption for indirect payments or transfers of value where the manufacturer does not know the identity of the recipient, so payments and transfers of value to speakers would remain exempt under that rule, provided the manufacturer doesn't directly pay the speaker or provide the third-party organizers with a list of preferred speakers.

Monday, June 30, 2014

Physician recruiter sees continued plunge in private practive

One of the largest physician recruiters in the country says the market for private practice, at least among its clients, is drying up quickly.

According to an annual review by physician search firm Merritt Hawkins, less than one in 10 of the company's 3,158 search assignments between April 1, 2013, and March 31, 2014, were for independent practice settings, such as partnerships, solo offices, or concierge/direct pay practices.

The vast majority of assignments were for employed positions, with 64 percent going to hospitals and the remainder serving large groups, community health centers, or academic facilities.

By comparison, independent practice situations made up more than 45 percent of Merritt Hawkins' search assignments in 2004.

Researchers said the mounting economic and regulatory pressures of the Affordable Care Act and other changes in the health care landscape continue to fuel the shift of physicians, who typically view employed positions as more financially stable and free of the burdens of running their own practices.

Overall, there were 714 searches for family medicine, making it the most requested recruiting assignment for the company for the eighth year in a row. The next most-popular search was for internal medicine, with 235 assignments.

The average base salary for family medicine assignments during the study period was $199,000, the highest average in the last five years. That average salary is a little higher than the $190,907 found in a recent study of AAFP members.

"Concierge" and other practice models where patients directly pay the physician a retainer or other regular fee for increased access has also grown. Merritt Hawkins said it completed 32 searches during the past year for these positions – only 1 percent of total searches but an increase from 10 searches two years ago. 

The ongoing shift of medical reimbursement from models based on volume to those based on quality and value has been difficult for health care organizations, and it shows in the incentives used to attract physicians. Researchers said only 24 percent of the company's recruiting assignments included production bonuses based at least partly on quality and value, a decrease from 39 percent of assignments during the previous year.

Production bonuses based on Relative Value Units (i.e., the work units performed by a physician) are still the most common. Fifty-nine percent of assignments included that type of bonus versus 57 percent last year.

Tuesday, June 24, 2014

Medicare to expand its use of prior authorization

The Centers for Medicare & Medicaid Services (CMS) is looking to expand its requirements that it provide prior authorization before Medicare beneficiaries can receive certain medical devices or supplies.

In a May release, CMS said it plans to more than double the number of states where it has prior approval power over power mobility devices, launch new prior authorization trials for two types of non-emergency services, and get public comment on establishing prior authorization rules for a number of other devices and supplies it says are frequently prescribed to patients who don't need them.

Since 2012, CMS has operated the Medicare Prior Authorization of Power Mobility Device Demonstration in seven states:  California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS believes the demonstration project has been sufficiently successful and plans to extend it to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and Washington.

CMS will also launch two new payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. CMS hopes that information from these models, each being held in three states, will let officials fine-tune future policy decisions on the use of prior authorization in Medicare.

Finally, CMS has proposed to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that it believes are frequently prescribed but unnecessary. Through a proposed rule, CMS is soliciting public comments on the process and criteria for selecting durable medical items subject to the new rules. The deadline to submit comments is July 28, 2014.

You can find additional information on CMS's prior authorizations initiatives on the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, June 20, 2014

Average family physician income up, but not equally

Family physician income, on average, has risen, but a new study indicates a greater number of family physicians are finding themselves on the low end of pay.

The 2013 Practice Profile Survey, a proprietary report issued in May, polled almost 500 American Academy of Family Physician (AAFP) members and found the average individual income in 2012 equalled $190,907. That's the highest average since the AAFP began surveying its members more than 30 years ago. However, the report noted that the median income was $170,000. A third of respondents said they earned $120,000 or less; a quarter of respondents said they earned more than $210,000.

"This suggests that the income levels among physicians are separating," the researchers wrote. "The separation is supported when the responses are categorized by income, as the percentage of respondents in the lowest category (earning $120,000 or less) was higher yet the mean income earned continued to grow."

When adjusted for inflation, the 2012 average still rises above previous years, but the median is similar.

Other survey findings include the following:

• Respondents said they worked an average of 48.3 hours a week in 2013, a decrease from 51.7 hours in 2012. Of that, they spent 34.1 hours in direct, face-to-face patient care, which was actually an increase from the previous year but similar to 2010 levels. The average amount of time spent on non-patient-care duties was down in 2013, falling to 2.6 hours per week, compared with 4.4 hours in 2012 and 4.8 hours in 2010.

• Sixty-eight percent of respondents said they were familiar with accountable care organizations (ACOs) and 28 percent said their practice was engaged in an ACO initiative. These are both increases over previous years as the ACO model continues to grow.

• Forty-two percent said they were familiar with the direct primary care (DPC) model. But only 2 percent of physicians said they currently worked in a DPC practice and 1 percent said they were transitioning to the DPC model.

• Twenty-six percent of respondents said their practice was recognized as a patient-centered medical home (PCMH), up from 24 percent the previous year. Nine percent said their practice had completed the transition and had applied for PCMH recognition. There was a slight decline in the percentage of physicians saying their practices received care management fees (44 percent), enhanced fee for service (37 percent), or shared savings amounts (13 percent) because of their inclusion in a PCMH. However, the percentage saying they received pay-for-performance amounts increased from 33 percent to 44 percent last year. Overall, 97 percent of respondents in a PCMH said their practice planned to reapply for PCMH recognition when the time came.

Tuesday, June 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections 30.6.9.1, 30.6.9.2, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 10, 2014

Potential pitfall in Medicare billing: modifer misuse

Over the past two weeks, we have discussed how to avoid common Medicare billing errors recently identified by the Centers for Medicare & Medicaid Services (CMS). This week, we’ll focus on the pitfalls associated with a commonly used billing modifier.

There are times when family physicians do multiple, separate procedures on the same patient at the same session or on the same day, for which separate payment may be allowed. Medicare rules state that the second and any subsequent procedures are subject to reduced payment in this situation. Physicians are to identify such services by appending modifier 51 (multiple procedures) to the codes for the second and subsequent procedures. Medicare, in turn, reduces the payment allowance by 50 percent for codes with modifier 51 attached.

Unfortunately, the CMS has identified situations in which physicians are appending modifier 51 to a procedure code even when that procedure is the only one provided to the patient on that date. In those situations, the physicians are generating inappropriate underpayments of up to 50 percent and shooting themselves in the foot financially. The easy answer is to NOT append modifier 51 to any code in the surgery section of Current Procedural Terminology (codes 10021 to 69990) if that is the only code from that section provided to the patient on that date.

For further resources, CMS advises that you read section 40.6 of chapter 12 and section 30 of chapter 23 of the Medicare Claims Processing Manual. Next week, we’ll wrap up this series of posts by looking at the pitfalls associated with billing office visits for hospital inpatients.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 3, 2014

Potential pitfall in Medicare billing: preventive services

Last week, we began looking at some of the common Medicare billing errors identified by the Centers for Medicare & Medicaid Services (CMS) in its most recent Medicare Quarterly Provider Compliance Newsletter. This week, we’ll focus on another of those pitfalls, this one associated with Medicare-covered preventive services.

In recent years, the CMS has expanded Medicare coverage of preventive services to include many recommended with a grade of A or B by the United States Preventive Services Task Force. These services (and their corresponding Medicare billing codes) include:

•    Annual alcohol misuse screening, 15 minutes (G0442)
•    Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)
•    Annual depression screening, 15 minutes (G0444)
•    Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes (G0446)

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

•    No record of the amount of time spent providing a timed service
•    No record of the billed service itself
•    No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

•    Record start and stop times, or the total time spent, when providing a timed service
•    Sign entries in medical records at the time of service
•    Learn about the non-covered indications and frequency limits for preventive services under Medicare

To the last point, you should know that:

•    Screening for depression is not covered when performed more than once in a 12-month period
•    Alcohol screening is not covered when performed more than once in a 12-month period
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than once a day
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than four times in a 12-month period.

You can find additional information and links to other relevant resources in the newsletter. Next week, we’ll look at the pitfalls associated with misuse of a common coding modifier.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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