CMS providing some help on vaccine-related E/M coding change
The Centers for Medicare & Medicaid Services (CMS) is providing some limited relief to physicians dealing with recent changes to how they're paid for vaccinations.
As this blog covered previously, the Jan. 1 round of Correct Coding Initiative (CCI) edits required that providers append modifier 25 to evaluation and management (E/M) services performed in connection with immunization administration services (90460-90474) provided on the same date to the same patient or only get paid for the immunization administration.
Subsequent to that post, I learned that CMS sent an alert on Feb. 1 to all state Medicaid agencies. The alert allows each state to deactivate the edits as they pertain to preventive medicine service codes (99381-99397) and immunization administration codes, retroactive to Jan. 1.
The deactivation is only applicable for the first quarter (Jan. 1-March 31, 2013). It's also up to each individual state Medicaid agency, and each state that does deactivate the applicable edits will have to individually decide whether to reprocess Medicaid claims already submitted since the beginning of the year.
CMS said it expects that state Medicaid agencies that choose to retain the edits will educate physicians on the proper E/M coding and use of modifier 25 to bypass the edits.
CMS has not made any unilateral decisions to deactivate these CCI edits nationally at this time, so outside of Medicaid in those states that choose to deactivate them, the new edits remain a hassle.
Still, some relief is better than none, and the American Academy of Family Physicians and other medical societies are continuing to ask CMS to rescind the edits at all levels.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Pay attention, or don't get paid for E/M services performed with vaccinations (UPDATED)
Getting fully reimbursed for vaccinations is now requiring a little extra effort.
The latest round of edits for the Correct Coding Initiative (CCI) went into effect Jan. 1 and included around 300 changes that affect evaluation and management (E/M) services and immunization administration, specifically codes between 90460 and 90474.
In each edit, the administration code trumps the E/M code. That means if you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append a modifier to the E/M code, Medicare and other payers who follow the CCI edits will only pay for the vaccine administration.
The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M code.
If, however, the situation merits separate reporting and you have supporting documentation, you can attach a modifier (such as modifier 25) to the E/M code and report both services. The one exception is E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration. That edit is not new.
Both the American Academy of Family Physicians and American Academy of Pediatrics are protesting the new edits, saying they needlessly complicate physician billing practices and don't appear necessary under current CPT language.
They also worry that placing additional barriers to practices seeking proper payment for immunizations will lead to fewer people getting vaccinated. That's obviously a problem for both public and individual health and comes at a time when the Centers for Disease Control and Prevention has lamented the unacceptably low adult immunization rates in the United States.
Considering that the CCI is overseen by the Centers for Medicare & Medicaid Services, it appears once again that Uncle Sam’s right and left hands don’t know what each other are doing or that, even if they do, the consequences are just as disastrous.
2/14/13 UPDATE: CMS gives state Medicaid programs some leeway in following new vaccination E/M coding changes.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Putting E/M services on the RAC
In July, I posted about a report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG) which found that from 2001 to 2010, physicians increased their billing of higher level evaluation and management (E/M) codes in all types of E/M services. In that post, I encouraged you to make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, the Centers for Medicare & Medicaid Services (CMS) were likely to follow suit, and you needed to be prepared.
Well, it appears that CMS was paying attention, or at least its recovery audit contractors (RACs) were. This week, CMS alerted the American Medical Association (AMA) that it has approved the Medicare Region C RAC. The contractor for Region C, Connolly, is to begin conducting audits of coding for E/M services in physician offices, specifically CPT code 99215. According to the AMA, in the next several weeks Connolly will begin a complex medical review of code 99215 and will be permitted to extrapolate their findings based on a statistical sample of such claims. Connolly is the Medicare fee-for-service RAC contractor who conducts RAC audits in the following states:
- Puerto Rico
- U.S. Virgin Islands
However, it has not yet been announced if all or only a subset of these states and territories will be under review. As of this writing, Connolly has not posted this information and other details of the review on its website. These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future.
The American Academy of Family Physicians, the AMA, and 100 other state and specialty societies sent a letter to CMS in March 2009 strongly opposing RAC audits of E/M services. However, the OIG report apparently encouraged CMS, through its RAC auditors to do otherwise.
So, what's a family physician to do? I would argue that the advice given in my July post still applies: make sure that your documentation supports the level of E/M services that you are billing to Medicare. If you are subjected to a RAC audit, take some solace in the fact that, according to CMS' FY 2010 Recovery Auditor Report to Congress, 46 percent of the Medicare RAC determinations that were appealed were decided in the provider's favor. That means you have almost a 50/50 chance of prevailing in the long run. Of course, as John Maynard Keynes once observed, "In the long run, we are all dead." Hopefully, the prospects for physicians in this case are a bit more optimistic.
The old "new patient" conundrum
In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?
CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)."
A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?" If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her. If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established.
While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice.
Are you sure this patient is new?
There has long been confusion about whether to report a new or established patient visit when the physician providing the service is new to the group but has seen the patient elsewhere in the last three years or when the patient seen by Dr. A today has been seen by Dr. B of the same group at another of the group's locations.
It is more important than ever to clear up this confusion. Why? The recovery audit contractor for Medicare Region D, which covers 17 states, lists this among the issues that they are investigating. Other RACs and private payers may do the same.
It is easy for an auditor to produce a report showing new patient E/M service codes reported for a given patient. If these reports show that a patient was charged for new patient visits by the same physician or more than one physician in the same group with the same taxonomy number (specialty number) in the past three years, a request for records or, more likely, a request for a refund, may be generated.
How can you stay out of trouble?
First, make sure that everyone choosing E/M service codes in your practice understands the CPT and Medicare guidelines for reporting a new patient E/M service: Interpret “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management (E/M) service or other face-to-face service (for example, surgical procedure), from the physician or another physician of the same specialty in the group within the previous three years. Note that interpreting a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service does not affect the designation of a new patient. If a professional component of a procedure is billed but no E/M service or other face-to-face service with the patient has been performed in three years, then the patient remains a new patient for the initial visit.
Next, add a step to your pre-appointment or pre-billing process to review the patient's billing history in your practice management system and determine if any face-to-face service was billed for the patient within the past three years. If a service was provided within the past three years, determine if the patient's service must be reported as established based on the CPT and Medicare criteria.
This decision tree from FPM is a handy reference that can help you determine quickly whether the patient is new or established. Also see Emily Hill's article, which provides additional information on this topic.
The health plan two-step
Most folks have heard of the Texas two-step. The Texas two-step is danced with two quick steps and two slow steps.
The health plan two-step is even simpler. It is one step forward and one step backward. The latest demonstration comes courtesy of Aetna.
In February 2006, Aetna agreed to pay the full allowed amount for a standard evaluation and management (E/M) service (e.g., a problem-oriented office visit), when billed with modifier 25 and a preventive E/M service. In essence, Aetna agreed to pay the full allowed amount for both services. This was progressive compared to other payers, like CIGNA and UnitedHealthcare, who only pay the acute service at a rate of 50 percent when done at the same encounter as a preventive medicine visit. Of course, some payers completely bundle the acute visit into the preventive visit in that scenario, resulting in payment only for the preventive service.
Anyway, Aetna took the second step of the health plan two-step earlier this month. Effective Aug. 15, 2009, Aetna began applying concurrency rules when two E/M services are billed and allowed with modifier 25, meaning each additional service is paid at less than the full amount. Aetna considers the preventive medicine visit to be the primary service and payable at 100 percent of the allowed amount; it considers the eligible office, or problem-focused, E/M to be the secondary service payable at 50 percent of the allowed amount. Apparently, there are others, like Aetna, who also giveth and taketh away.
The only upside that I can find in this particular dance is that Aetna's policy is now consistent with others' policies, so you have one less exception to remember. On the other hand, as Ralph Waldo Emerson once observed, "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." I guess Aetna thinks a lot of it, too.
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.