CMS refuses to halt ICD-10-CM implementation
The Centers for Medicare & Medicaid Services (CMS) has denied a request from more than 80 state and national physician organizations, including the American Academy of Family Physicians (AAFP), to halt implementation of ICD-10-CM.
The Dec. 20, 2012, letter to CMS Acting Administrator Marilyn Tavenner requesting the delay argued that the new set of outpatient diagnosis coding would create additional, unnecessary burdens for America's physicians at a time when many are overwhelmed with other health care system demands and changes.
On Feb. 6, 2013, Tavenner declined the request and said that CMS will move forward with implementing ICD-10 on Oct. 1, 2014. She noted that this already represented a year’s extension beyond the original implementation date of Oct. 1, 2013. Tavenner also said that halting implementation at this point "would be costly, burdensome, and would eliminate the impending benefits" of the investments that many in the industry have already made with respect to implementation.
So, for now, ICD-10 proponents have carried the day, and everyone needs to look for strategies to ease implementation. If you have not already developed an implementation plan, here are some resources to help you.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Decoding the new transitional care management rules
Ever since their introduction at the beginning of the year, the new transitional care management (TCM) codes have caused confusion.
The Getting Paid blog described the new codes when they were first announced last fall. But the questions have continued, and the codes are getting additional attention after the CPT Editorial Panel clarified in January that transitional care management involving new patients, and not just ones that a physician has seen within the previous 12 months, could be billed using the TCM codes.
Here are some of the more common questions:
Q. When should I bill for TCM?
A. You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day after the discharge.
Q. What happens if the patient is re-admitted before the 30 days are up?
A. The face-to-face visit would become the appropriate level evaluation and management code for the service that was rendered. You would restart your 30 days of service on the TCM once the patient was discharged.
Q. Does a discharge visit count as the post discharge contact?
A. No, a discharge visit does not count. The initial contact must be made after the patient leaves the hospital. This is to make sure that the patient has the support necessary until they have their face-to-face visit. The initial contact can be phone, e-mail, text, or face-to-face. It can involve the patient and/or the patient's caregiver.
Q. If the patient needs an unrelated evaluation and management (E/M) visit during the 30 days can I bill for this?
A. Yes, although there are some restrictions on what you can bill, such as anticoagulation management and home health care certification.
We’ve yet to hear how these codes are getting paid since the earliest billing date would have been Jan. 30, 2013. We are also waiting on the Centers for Medicare & Medicaid Services (CMS) to release guidelines on the codes, which we expect to receive by the end of February.
AAFP has created a form to help you document the requirements of TCM visits and made available for download a list of frequently asked questions. TCM was also discussed as part of an AAFP/TransforMED webinar, “What’s new in Medicare and Medicaid payment in 2013,” which is archived on TransforMED's Delta Exchange site and accessible to AAFP members upon login.
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
Begin the Beguine, or loosening up for some ICD-10 dance steps
Is it necessary to love big band jazz in order to properly understand the new ICD-10 coding? No, but it would certainly help with the fancy footwork involved.
The "Getting Paid" blog will address in coming posts what major changes to look for in specific chapters of ICD-10. In the meantime, we'll look at the new coding system's Conventions and Guidelines. These are all available for download on the CDC website.
First off, ICD-10-CM has 21 chapters, up from 17 in ICD-9-CM as codes for certain conditions either break off to form their own sections or get roped in with others. The V and E codes, which detail supplemental factors influencing a patient's health and the external causes of injury, will be incorporated in the main classification under ICD-10-CM. Meanwhile, diseases and conditions of the eyes and ears will get their own chapter, separated from their current home in the nervous system section.
Injuries will now be classified by site, and then by type. Postoperative complications have been moved to procedure-specific body system chapters. Also, some codes have been combined. For example, coding for type 1 diabetes mellitus with diabetic neuropathy will no longer require two codes (one for the diabetes and one for the neurological manifestation) but a single code of E10.21.
In ICD-10-CM, as with ICD-9-CM, notes and parenthetical instructions are still present. The manual will still use "code first" and "use additional code," as well as "includes" and "excludes" notes. Also remaining are "not otherwise specified (NOS)" and "not elsewhere classified (NEC)." The term "and" is interpreted to mean "and/or" when it appears in a code title within the tabular list. The word "with" is interpreted to mean "associated with" or "due to" when appearing in a code title.
On the other hand, certain symbols, such as the lozenge, section mark, and braces are disappearing. Instead, ICD-10 will use dashes at the end of a code to signal that it requires additional characters. One example is M84.47-, which could represent any fracture to an ankle, foot, or toe (M84.472 is a fractured left ankle). ICD-10 does two types of "exclude" notes to modify some codes. "Excludes 1" lists condition codes that can't be used at the same time as the primary code. "Excludes 2" notes conditions that are not part of the primary code but that a patient could present at the the same time, meaning that both codes being used together are acceptable.
The alphabetic index of ICD-10 is divided into two parts – the index to diseases and injuries and the index to external causes – while the type and format layout uses the same mechanics as ICD-9. Morphology codes are no longer listed in the alphabetic index, and they no longer have a separate appendix in ICD-10.
As I said earlier, the tabular list is divided into 21 chapters. Some of the reclassifications of diseases to different chapters were done for better alignment. Each chapter is then divided into subchapters that contain three characters and are similar to the ICD-9 foundations. Each chapter in ICD-10 begins with a summary of the blocks and an overview of the categories within the chapter. Some of the subchapters are divided into even more specific subchapters.
The takeaway? With all of the changes ahead with ICD-10, getting up to speed will likely be less of a graceful waltz and more of a frantic jitterbug. But the AAFP is here to help you get through it.
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
CMS approves new codes for Transitional Care Management
CMS has approved paying two new codes for care
management of patients transitioning from an inpatient hospital setting
(including acuity, rehabilitation, or long-term acute care), partial hospitalization,
or observation status in a hospital, skilled nursing facility, or other nursing
facility to the patient’s community setting (home, domiciliary, rest home, or
These new codes are based on the complexity of
medical decision-making and the amount of time between discharge and the
patient’s first face-to-face visit with the physician or other qualified health
care provider. Code 99495 requires moderately complex medical decision-making
and a face-to-face visit within 14 days. Code 99496 requires highly complex medical
decision-making and a face-to-face visit within seven days.
Transitional care management (TCM) is based on the CMS Evaluation and Management Guidelines. Medical decision-making consists of three components: (1) Diagnosis and Management, (2) Data Reviewed, and (3) Table of Risk. Ideally the first place to look is the table of risk. If the patient falls under the minimal or low section of the table of risk it is highly unlikely they will qualify for either of these codes. However, you need to review all three components to determine the appropriate level.
Both codes require communication with the patient or caregiver within two business days of discharge by telephone, direct contact, or electronic means, and that, by the first face-to-face visit following discharge, the patient’s medications be reconciled with the medications listed on the patient’s chart.
The physician or other qualified health care provider may provide the following non-face-to-face services:
• Obtaining and reviewing the discharge information (e.g., discharge summary or continuity of care documents).
• Reviewing and follow-up of pending diagnostic tests and treatments.
• Interaction with other qualified health care professionals who will assume or re-assume care of the patient’s system-specific problem.
• Education of patient, family, guardian, and/or caregiver.
• Establishment or re-establishment of referrals, and arranging community services, if needed.
• Assistance in scheduling any required follow-up with community providers and services.
Clinical staff under direction from a physician or
other provider can provide such non-face-to-face services as communicating
aspects of care, self-management and treatnment regimen adherence with the
patient, caregiver, or other decision maker, as well as communicating with home
health agencies or other community services the patient is using. They can also help identify available
community resources for the patient and help get them access.
You cannot charge an office visit on the same day as your face-to-face visit for TCM. However, you can be the discharging physician and bill the discharge and then the TCM. Only one physician may bill the TCM and it can only be billed once per 30 days, even if the patient has another hospitalization and discharge.
CMS has valued Code 99495 at 4.82 total RVUs, or
about $163. Code 99496 is valued at 6.79 RVUs, or approximately $230.
These codes are ideal for a strong team approach, covering services many family physicians are providing on a regular basis, and recognizing that primary care physicians take care of many time-consuming issues of care coordination for patients.This is a start in the right direction. Happy Transitioning!
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
Screen before you counsel for alcohol misuse
The Centers for Medicare & Medicaid Services recently issued further instructions for contractors processing claims for the preventive medicine benefit for alcohol misuse counseling, which was added last fall. If a claim is submitted for code G0443 (brief face-to-face behavioral counseling for alcohol misuse, 15 minutes) when there are no claims for code G0442 (annual alcohol misuse screening, 15 minutes) in the prior 12 months, the contractor will deny the claim for G0443. The article also reminds contractors and physicians that Medicare will only pay for up to four G0443 services within a 12-month period. Claims for G0443 that exceed that four session limit in a 12-month period will be rejected.
Some other reminders about these services:
- Medicare will allow payment for both G0442 and G0443 on the same date (except in rural health clinics and federally qualified health clinics), but will not pay for more than one G0443 service on the same date.
- Code G0442 is an annual benefit so at least 11 months must pass between services.
- Both the screening and counseling services have time elements of 15 minutes, so time should be documented in addition to screening or counseling notes.
- Counseling for alcohol misuse must be based on the Five As (Assess, Advise, Agree, Assist, and Arrange), so be sure your documentation reflects this.
- The alcohol screening and counseling services are payable with another visit on the same day (e.g., office visit for other problems), except for the Initial Preventive Physical Exam ("Welcome to Medicare" physical).
- These services are not subject to deductible or co-insurance.
- National average fee schedule amounts for these services are $17.36 for G0442 and $25.19 for G0443.
You can find further details on this and other preventive medicine benefits covered by Medicare Part B in Chapter 18 of the Medicare Claims Processing Manual.
Additional Documentation Requests: Don't ignore them
Family physicians in the Medicare J5 MAC region states of KS, MO, NE, and IA providing inpatient care should be prepared to receive and promptly respond to letters from the WPS Medicare Medical Review Department. These will be related to prepayment review of claims for subsequent hospital visits submitted with code 99233. WPS notes that their Comprehensive Error Rate Testing (CERT) reviews of paid claims have shown a significant increase in errors on claims for these services by family physicians. If one of your claims is selected for review, WPS will send an Additional Documentation Request (ADR) for medical records for all dates of service billed with CPT code 99233.
Breathing a sigh of relief because you are not in one of the J5 MAC states? I can see that. No one wants their payments delayed and subjected to prepayment review and potential denial or down-coding. But if your Medicare CERT or one of the myriad other Medicare auditors isn’t looking at your inpatient hospital services, I would bet they are looking at some other evaluation and management (E/M) service that may have been inadequately documented or incorrectly coded. If post-payment review results in a high error rate, you too may find your payments delayed, reduced, or denied.
So what can you do to avoid problems?
First respond promptly and completely to all ADR letters. Many claims are denied and counted as errors due to lack of response to ADR's. See the information previously provided in this blog for details.
Second, be sure that documentation submitted is clear, complete, appropriately signed, and dated. Did you and your partner provide E/M services on the same date and bill the services according to Medicare rules as one E/M service? Will both notes be sent? If not, your 99233 visit may be down-coded to 99231 or 99232. A records request checklist can help your staff submit all of the information necessary to support your charges.
Are you using 99233 only when the patient is unstable or has developed a significant
complication or a significant new problem? If billing based on time, have you
documented counseling and coordination of care for at least half of a visit
(including hospital floor time) of 35 minutes or more?
Are you using 99233 only when the patient is unstable or has developed a significant complication or a significant new problem? If billing based on time, have you documented counseling and coordination of care for at least half of a visit (including hospital floor time) of 35 minutes or more?
Finally remember, code 99233 requires at least two of these three components:
• A detailed interval history – state progress or complications since last visit, if referring to previous history state date of previous history, chief complaint or reason for visit beyond “follow-up,” HPI (4 items or 3 conditions), ROS (2-9 systems), PFSH (none necessary);
• A detailed examination – Extended exam of problem system/areas plus others;
• Medical decision making of high complexity (2 of 3 elements, not risk alone) – established problem(s) worsening; new problems with or without further work-up; changes in treatment, nursing instructions, decisions for palliative care, tests and procedures ordered (note if urgent), tests reviewed and unexpected results, discussions with other physicians, risks of management and treatment.
It is complex and probably annoying but remember, it is necessary to show the work (talking, reviewing, thinking) that you did to support your charges. A 99233 service should not go unpaid due to lack of response to ADRs, unsigned records, or other documentation gaps.
E-Prescribing codes for 2012
Wondering what codes to report to demonstrate e-prescribing in 2012? If you electronically prescribed during the eligible patient visit, submit code G8553, which denotes that at least one prescription created during the encounter was generated and transmitted electronically using a qualified e-prescribing system. Eligible patient visits are those reported with any of the following CPT or HCPCS codes:
90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.
To demonstrate that you are exempt from e-prescribing, submit code G8642, which connotes that "the eligible professional practices in a rural area without sufficient high-speed Internet access" and G8643, "The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing. There are no codes to report exemptions resulting from the inability to electronically prescribe due to state, federal, or local law or regulation" or as an "eligible professional who prescribes fewer than 100 prescriptions during a six-month payment adjustment reporting period." These exemptions must be requested by the physician through http://www.qualitynet.org/pqrs.
A Remittance Advice (RA)/Explanation of Benefits (EOB) with the denial code N365 is your indication that the e-prescribing G-code was received by Medicare.
Transparency and Medicare auditing: Who's cheating whom?
I might not always agree with a speed limit that seems too high or too low. In fact, some seem to serve to disrupt a smooth traffic flow or fail to recognize areas where a slower speed might be more practical. However, I appreciate clear and accurate signs of what the speed limits are so that I have the opportunity to obey and avoid inadvertently breaking the law.
Earlier this year, I wrote in Family Practice Management about differences in the guidance given about evaluation and management (E/M) coding and documentation by Medicare Administrative Contractors. I have since learned that one contractor, with the support of the Centers for Medicare & Medicaid Services, still refuses to post their speed limits.
Under the guise of protecting the Medicare program from fraud and abuse, one Medicare contractor refused a request for information from a group of coding professionals who want to be sure that the physicians they work with are selecting their E/M codes with the same criteria as the Medicare contractor who might audit them.
The coders know that other Medicare contractors routinely provide this information on their web sites:
Some private payers' score sheets are also transparent:
Needless to say, the contractor's refusal didn't sit well with folks who are dedicated to trying to help physicians understand and follow the rules. The coders used the Freedom of Information Act (FOIA) to request the information they needed, first by filing a formal request to the contractor's FOIA contact and then to CMS, after being advised by the contractor to apply directly to CMS. More than a year later, here is the response the coders received:
"Exemption 2 of the FOIA (5 U.S.C. 552(b)(2)) protects documents or portions thereof 'related solely to the internal rules and practices of an agency.' It also protects administrative enforcement manuals the disclosure of which would harm the agency’s ability to properly administer the program. The auditing guidelines are for the use of government reviewers and examiners. Release of these guidelines would risk circumvention of agency regulations without detection by parties subject to such regulations."
Perhaps the people who responded to this request have never seen the first and last of Medicare's four strategies for paying claims correctly:
"The Centers for Medicare & Medicaid Services (CMS) follows four parallel strategies in meeting this goal: 1) preventing fraud through effective enrollment and through education of providers and beneficiaries, 2) early detection through, for example, medical review and data analysis, 3) close coordination with partners, including PSCs, ZPICs, ACs, MACs, and law enforcement agencies, and 4) fair and firm enforcement policies." (Source: Program Integrity Manual Chapter 4, accessed 10/27/10)
Shouldn't education of providers include full disclosure of the measures they need to meet? Is it fair to determine that a level of service is incorrect without disclosing the criteria on which the determination was based?
If anyone from CMS or the Medicare contractor who made this decision happens to read this blog, please recognize that even using the score sheets for E/M services, many physicians find the rules difficult to interpret, and few have the time or desire to figure out how to use these to "circumvent" the regulations. If you will provide clear and easily accessible information on what you expect, I think you will find that the majority of physicians will follow your lead. Anyone who purposefully charges for higher levels of service than they provide or document probably thinks they will never be audited anyway.
Accountable care organizations and the future of physician payment
As promised in the meeting agenda, an FTC panel debated circumstances under which independent health care providers participating in an ACO could engage in price point negotiations with private payers without running afoul of federal antitrust laws that prohibit price-fixing. Also, panel participants explored different ways in which the HHS secretary could exercise waiver authority or create new exceptions and safe harbors related to the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalty law, for the purpose of encouraging the creation and development of ACOs. The AAFP submitted comments that were included in the meeting record, and the Academy will continue to track the progress of the issues discussed.
New tobacco-use cessation counseling benefits: Three billing scenarios
The Centers for Medicare & Medicaid Services released guidance this week on payment for expanded smoking and tobacco-use cessation counseling. This service is now covered for patients who use tobacco but do not have symptoms of related conditions, and the coverage is retroactive to Aug. 25, 2010. The counseling must be provided by a physician or other qualified health care professional (e.g., physician assistant).
Now for the not-so-good news. Allowing different benefits for the same service based on whether it is preventive or problem-oriented creates coding and payment guidelines that are, well, problem-oriented. Here's what I mean:
While asymptomatic patients became eligible for the counseling benefit on Aug. 25, 2010, the full benefit of the preventive service coverage does not begin until Jan. 1, 2011. For services delivered from Aug. 25, 2010, to Dec. 31, 2010, charges will be subject to any unmet deductible and to the patient's co-insurance. For dates of service Jan. 1, 2011, and after, the same services will not be subject to deductible and co-insurance (i.e., there will be no out-of-pocket expense for the patient who receives the service). This may require some patient education.
Here's what else you need to know to code and bill for these services now and in the future:
• For counseling provided to patients who use tobacco and have a condition that is adversely affected by tobacco use and/or are undergoing a treatment that is adversely affected by tobacco use, continue reporting CPT codes 99406 and 99407. The benefits for these patients have not changed. (If you're not familiar with these services, see the FPM article An Update on Tobacco Cessation Reimbursement.)
• For counseling provided to patients who do not have symptoms of conditions related to tobacco use and are not undergoing a treatment that is adversely affected by tobacco use, report unlisted CPT code 99199, "Unlisted special service, procedure, or report" for dates of service Aug. 25, 2010, through Dec. 31, 2010. Submit ICD-9 codes 305.1, "Non-dependent tobacco-use disorder," or V15.82, "History of tobacco use," as well. Be sure to inform patients that unless there is a secondary insurance that pays the balance after Medicare, they may be responsible for an unmet deductible and for co-insurance amounts.
• For counseling provided to asymptomatic patients beginning on Jan. 1, 2011, you should bill using the new Medicare G codes: G0436, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes," or G0437, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes." The same diagnosis codes, 305.1 or V15.82, will be required. Again, patients will not have an out-of-pocket expense for these services when they are delivered on Jan. 1, 2011, or after.
When reporting any significant and separately identifiable evaluation and management service on the same date as tobacco-use cessation counseling, append modifier 25 to the evaluation and management code.
These are some of the first changes for preventive services in response to requirements of the Affordable Care Act. There will no doubt be other guidance coming from CMS and private payers on coverage, coding, and payment for preventive services. Stay tuned, and we will deliver information as promptly as possible after its publication.
Get them while they're hot! And then, enjoy the freeze.
With time to spare, the editors of FPM magazine have provided not only an article describing the ICD-9 code changes that take place on Oct. 1, 2010, but an updated array of ICD-9 tools to help you bill the correct diagnosis codes for dates of service through Oct. 1, 2011.
The September/October issue of FPM includes the article as well as the FPM short list of ICD-9 codes for family medicine. The short list and a long list can be downloaded in PDF or Excel format from the ICD-9 resources page in the FPM Toolbox. The FPM superbill and a searchable ICD-9 database for PDA users have also been updated and can be downloaded there as well. Be sure to share these valuable resources with your staff.
We also have good news about future code updates. The ICD-9-CM Coordination and Maintenance Committee will implement a partial freeze of the ICD-9 and ICD-10 codes prior to the implementation of ICD-10 on Oct. 1, 2013.
The partial freeze will be implemented as follows:
- The last regular, annual updates to both ICD-9 and ICD-10 code sets will be made
on Oct. 1, 2011.
- On Oct. 1, 2012, there will be only limited code updates to both the ICD-9 and ICD-10 code sets to capture new technologies and diseases.
- On Oct. 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. There will be no updates to ICD-9, as it will no longer be used for reporting.
- On Oct. 1, 2014, regular updates to ICD-10 will begin.
The partial freeze should allow you, your staff, software vendors and payers to focus on ICD-10 training and implementation of ICD-10 codes for the next three years without having to also keep up with significant changes to either the ICD-9 or ICD-10 code sets.
During this time, FPM and the AAFP will continue to offer information and resources to help you through the ICD-10 training and transition and keep you up-to-date on any code changes due to new diseases effected during the freeze.
As the dust settles following the removal of the consultation codes from the 2010 Medicare fee schedule, a lot of questions remain. Unfortunately, some of the people trying to answer those questions are not providing sound coding advice. Most concerning is the idea that the outpatient consultation codes crosswalk directly to the office or other outpatient service codes. The very first cross in this walk should raise questions. Could a 99241 service with key components of a problem focused history and exam and straightforward medical decision making realistically cross to a 99211 nursing visit? No. This service is much more likely going to meet the key components of a 99212 service. The difference is significant. The national average Medicare fee schedule amount for a 99211 is $19.12 while the national average amount for a 99212 is $38.97. By using someone's idea of a time-saving crosswalk rather than selecting the code that your documentation support, you could lose half the revenue your practice earned for this service. Physicians should also be aware that hospital or nursing facility consultations that meet the key components of 99251 or 99252 do not satisfy the key components for 99221 or 99304, which require higher levels of history and examination. The bottom line is that services should be assigned the code that the documentation supports. You should not cut corners by crosswalking the codes. This may be especially important to consider if you are billing a patient's private payer plan first and Medicare second. You may be able to bill the private plan for a 99251 service but you cannot bill that same code to Medicare for the secondary payment. In this case, you must determine whether your Medicare contractor will accept a subsequent hospital care code even though this was the physician's first inpatient encounter with the patient. They may require you to submit code 99499 for an unlisted E/M service instead, leaving them decide what level of service was rendered. This move by Medicare to eliminate consultation codes from the fee schedule has shown just how complex E/M coding has become.Let's hope we can move toward a simpler system where physician work (i.e. level of history, exam, medical decision making, counseling and coordination of care) is fully valued with or without a request for advice or opinion. Now if there could be a closer look at all those E/M services valued into the global fees for surgery...
As the dust settles following the removal of the consultation codes from the 2010 Medicare fee schedule, a lot of questions remain. Unfortunately, some of the people trying to answer those questions are not providing sound coding advice. Most concerning is the idea that the outpatient consultation codes crosswalk directly to the office or other outpatient service codes.
The very first cross in this walk should raise questions. Could a 99241 service with key components of a problem focused history and exam and straightforward medical decision making realistically cross to a 99211 nursing visit? No. This service is much more likely going to meet the key components of a 99212 service. The difference is significant. The national average Medicare fee schedule amount for a 99211 is $19.12 while the national average amount for a 99212 is $38.97. By using someone's idea of a time-saving crosswalk rather than selecting the code that your documentation support, you could lose half the revenue your practice earned for this service.
Physicians should also be aware that hospital or nursing facility consultations that meet the key components of 99251 or 99252 do not satisfy the key components for 99221 or 99304, which require higher levels of history and examination.
The bottom line is that services should be assigned the code that the documentation supports. You should not cut corners by crosswalking the codes. This may be especially important to consider if you are billing a patient's private payer plan first and Medicare second. You may be able to bill the private plan for a 99251 service but you cannot bill that same code to Medicare for the secondary payment. In this case, you must determine whether your Medicare contractor will accept a subsequent hospital care code even though this was the physician's first inpatient encounter with the patient. They may require you to submit code 99499 for an unlisted E/M service instead, leaving them decide what level of service was rendered.
This move by Medicare to eliminate consultation codes from the fee schedule has shown just how complex E/M coding has become.Let's hope we can move toward a simpler system where physician work (i.e. level of history, exam, medical decision making, counseling and coordination of care) is fully valued with or without a request for advice or opinion. Now if there could be a closer look at all those E/M services valued into the global fees for surgery...
You might be a coding and payment geek if . . .
The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people. So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:
10. The first thing you associate with December is the arrival of the new CPT book.
9. You actually get excited when your new coding books arrive.
8. You wonder why the toy doctors bag you bought your kid doesn't include a claim form.
7. You worry your family physician is undercoding your visit.
6. You consider the Federal Register light reading.
5. You write to CMS more than to your own mom.
4. You actually understand Medicare's Sustainable Growth Rate formula.
3. You collect past issues of CPT Assistant on eBay.
2. When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.
And the number one sign that you might be a coding and payment geek:
1. You actually understood the humor in this blog post!
Getting paid for H1N1-related services
Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?
Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.
Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.
Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.
Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.
The trouble with consultations
In a rather surprising move, the Centers for Medicare and Medicaid Services (CMS) included in the proposed rule on the 2010 Medicare physician fee schedule a proposal to remove codes for consultations from the Medicare fee schedule. Physicians instead would report the office/outpatient, hospital, or nursing facility evaluation and management (E/M) visit codes as appropriate, and these codes would be awarded higher relative value units (RVUs) in the fee schedule, resulting in potentially higher payment. Whether these increased payments would make up for the elimination of the higher-paying consultation codes likely depends on each individual physician’s mix of consults and office/hospital visits and the percentage of established patients versus new patients.
Some physicians won't like this, as it redistributes payment for E/M services among all physicians. These physicians state that their work is always worth more money because of the additional education and training they have related to specific medical problems. What they may be missing is that Medicare is offering a carrot, an increase in RVUs for non-consult E/M codes and fewer of the coding and documentation burdens that were associated with consultation codes.
At the same time, the Medicare auditors are bringing out the sticks in the form of pre-payment and post-payment audits. Medicare's Comprehensive Error Rate Testing (CERT) Report for May 2008 specified a high "paid claims error rate" of 16.6 percent for consultation services, with a projected improper payment of $516,912,824. Incorrect coding accounted for 86.4 percent of the consultation coding errors. WPS, Medicare contractor for Iowa, Kansas, Nebraska and western Missouri is performing a widespread probe of all consultation claims submitted and requiring pre-payment submission of medical records to substantiate charges. Other Medicare contractors have also chosen consultations for review. Given the state of Medicare funding, can the administrators ignore these results and not attempt to collect (with interest) the money paid out for these consultation services? Will Medicare's Recovery Audit Contractors, who receive a percentage of all money returned to Medicare, ignore these findings? If it were me, I'd accept the carrot and hope the stick is eventually aimed elsewhere.
The proposed removal of consultation codes from the Medicare fee schedule is mostly positive for family physicians, since you seldom get the benefit of the higher payment associated with consultation codes despite doing extensive work-ups before referring patients to subspecialists for specific procedures. However, there could be a drawback in that the higher payment was an incentive for the subspecialists you refer to to promptly report back to you, as the consultation codes require. There is some danger that removal of the incentive will cause greater delays or failure of communication, making it more important than ever that your staff keep logs (automated or manual) to be sure that you are aware of all physicians caring for your patients and follow-up as needed to receive records or reports. If you don't have systems in place to help track referrals, lab tests, etc., consider downloading the AAFP's Road to Recognition guide. Though created to help physicians document the elements necessary for recognition under the National Committee for Quality Assurance's Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH), the simple tracking tools it includes may be useful in many practices. If you feel certain that you always receive timely written follow-up from consultants, using these tools will provide you with evidence of whether your feelings are matched by your results.