Part B Billing: Updates on Difficult Topics; Introduction to Getting and Using Billing Reports

1. Part B Billing: Updates on Difficult Topics; Introduction to Getting and Using Billing Reports Wednesday, April 11, 2012 Audio Conference 1:30 – 2:30 PM EST • Lynn Hill Spragens, MBAPresident & CEO Spragens & Associates, LLC • Consultant to CAPC • Durham, NC • E-mail: Lynn@LSpragens.com Julie Pipke, CPCReimbursement Manager Department of Medicine Medical College of Wisconsin Consultant to CAPC Milwaukee, WI E-mail: jpipke@mcw.edu

2. Learning Objectives • In this audio conference, you will learn: • Improved approaches to documentation that reduce denials • Priorities for reviewing billing results • (Relatively) easy ways to convert billing data into usable management information

3. Outline • Updates, examples, & advice on specific billing issues (Julie) • “New Patient” Definitions • “Face-to-Face” documentation • Billing for Time/Prolonged time • Medical team conferences • Getting and using billing reports (Lynn) • Q & A

4. Issue 1: “New Patient” Definition On the CAPC Forum, several questions have revealed confusion about when to bill for a new patient visit The definitions for inpatient care and outpatient care are DIFFERENT. Confusion was added when CMS discontinued use of “consult” codes in 2010.

5. Definition of “New Patient” (Outpatient) • CPT 2012: A patient that has not received any professional services* from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. * Professional services are those face-to-face services rendered by a physician and reported by a specific CPT code.

6. New Patient (Outpatient) • 99201-99205 are the only codes in CPT that are specifically for NEW patients only. • The term “NEW” patient does not correlate to any inpatient E/M services. • Outpatient consultations billed to Medicare must cross to the appropriate code. If the patient has been seen in the last 3 years by a provider in the same specialty group practice, you must use the established patient visit codes 99211-99215.

7. Outpatient Consult Example • Dr. BMT requests a PC consultation for a Medicare patient for pain management and goals of care. • Dr. PC sees the patient and submits a bill to his coder for a level four consultation (99244). • The coder sees that the patient is covered by straight Medicare and reviews the records to see if anyone in the group practice (same specialty) has seen the patient in the last 3 years. If the patient has not been seen in the last three years, the appropriate cross code is 99204. If the patient has been seen in the last three years, the appropriate cross code is 99215.

8. New Patient (Inpatient) • Each CMS-recognized specialty can bill for one consultation during each inpatient stay provided that the service rendered meets the definition of a “consultation”. • If a patient is re-admitted several times within a year/month/week and during each stay Palliative Care is asked to perform a consultation, the appropriate consultation code or cross-code should be billed(depending on payer) • The patient does not have to be new to the specialty group and there isn’t any policy that states a certain time period must be met before another consultation can be performed and billed.

9. Inpatient Consults CONSULTATION: a kind of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source.

10. Issue 2: “Face to Face” (F2F) Payment in some cases is limited to F2F time. Confusion re how to document when care is mixed (some F2F, some with family or out of room), or if with legal surrogate. Tension between appropriate documentation of workload vs. payment. Advice re F2F tied up in advice re documentation for TIME.

11. Issue 3: Billing for Time Prolonged service codes Documentation examples Time vs. Elements

12. Prolonged Care Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated E/M services provided at the same session as E/M services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c12.pdf (bottom page 83)

13. CPT Codes for Prolonged Care 99354 & 99355 Prolonged Service in the office or other outpatient setting, requiring direct patient contact. 99356 & 99357 Prolonged Services in the inpatient or observation setting, requiring unit/floor time beyond the usual service. 99358 & 99359 Prolonged E/M service before and/or after direct patient care. When the E/M service is billed base upon time, the amount of time spent must exceed the typically time assigned to the highest LOS within the category (New, Consult, Established).

14. Inpatient: AMA vs. CMS • CPT/AMA 99356 floor/unit time first 30-74 minutes 99357 floor/unit time each additional 30 minutes. • CMS doesn’t allow providers to use 99356 & 99357 for any amount of time that wasn’t spent directly face-to-face with the patient. Time spent without the patient being present cannot be billed using these codes; only bill with 99358 & 99359.

15. Prolonged Care – Inpatient (CMS specific rules) Unlike their Critical Care policy, CMS does not allow for any reimbursement to providers’ for their discussions with family members or surrogate decision makers unless the patient is present during those discussions. CMS requires the providers to document the in and out times in the medical record for CPT codes 99356 & 99357. Some other payers may handle differently.

16. Inpatient Prolonged Care Palliative Care Consult Note “I spent a total of 180 minutes unit/floor time today, 12:35 to 15:35 of which >50% were spent in counseling and coordination of care. 100 minutes were spent F2F with the patient. I counseled the patient today about hospice care and it’s philosophy focusing on comfort, safety…” Medicare: 99223 (70min f2f) 99356 (remaining 30min f2f) 99358,99359 (80min non f2f) Commercial: 99255, 99356

17. Why Bill 99358 & 99359? • CMS and many other carriers will not reimburse. • Some carriers will pay with first claim, others pay upon appeal with medical records. • Many practices set RVU benchmarks for their providers so capturing every RVU is important. • 99358 = 2.10 work RVU’s (99233/99215) • 99359 = 1.00 work RVU’s (99251/99213)

18. Outpatient Prolonged Care “ I spent 80 minutes with the patient and spouse in clinic today >50% spent in counseling & coordination of care. The patient has a solid tumor cancer that is untreatable; she is appropriate for hospice care as her prognosis is likely less than 6months. No changes will be made to her pain regimen, her pain is well managed. We discussed end of life planning; we will arrange for a hospice information visit to her home. She’s also concerned about LE swelling, so I’ve ordered an ultrasound to evaluate for DVT.” All Payers: 99215, 99354

19. Time Based vs. Element Based Prolonged services codes can be billed only if the total duration of the physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).

20. Element Based • 1st note: Documented expanded problem focused history, detailed exam with high decision making (99233). • 2nd note: Spent 45 minutes with the patient and family discussing treatment/management options, all questions were answered; In 1825 Out 1910. Billed: 99233 Rationale: 35 minutes for the visit is subtracted from the 45minutes of f2f prolonged care time which only leaves 10 extra minutes. 

21. Time Based • 1st note: Documented total visit time 35 minutes, spent 25 minutes f2f with the patient • 2nd note: Spent 45 minutes with the patient and family discussing treatment/management options, all questions were answered; In 1825 out 1910 Billed: 99233, 99356 Rationale: When billing the visit based upon time, only the highest level of service in the category of codes being used can be billed if the prolonged care codes are also being billed. Medicare only allows us to use the f2f time for CPT codes 99356 & 99357, so we have to take 10 minutes from the prolonged visit to have the 35minutes required for 99233, we then have 35 minutes leftover which allows us to bill 99356 in addition.

22. Reasons to Bill Based Upon Time • In summary, the best way to document inpatient prolonged care is to bill all E/M services on that same day based upon time. Following the three steps below will ensure that all time is billed and billed appropriately.  • Document the visit based upon time (total time and the time that was spent f2f with the patient) • Document the prolonged care visit with total f2f time and total *non f2f time • Document the in and out times for all prolonged care visits

23. Issue 4: Ways to bill for Team Conferences Dilemma – we want to track contribution and time Better documentation can improve payment as more time is captured Reality – rules are tight, be careful

24. Medical Team Conference • 99366 - Team conference with interdisciplinary team of health care professionals, f2f with patient and/or family, 30 minutes or more, participation by non-physician qualified health care professional. • 99367 - patient and/or family not present, 30 minutes or more; participation by physician • 99368 - participation by non-physician qualified health care professional • Reimbursement for these codes is unlikely from any payer. • Guidelines in CPT should be reviewed very carefully before billing for these services.

25. OIG Top Ten Prolonged Care is on the OIG’s top ten hit list for 2012! Make sure that everyone understands the rules. Review provider documentation frequently to ensure the billing is supported by the documentation. If you’re uncertain, get some help. The CAPC website has a vast amount of information available to anyone who needs it.

26. Getting Billing Data / Report Strategies

27. Accounting Reports vs. Management Reports • Billing is a financial function – ties closely to monthly accounting rules • Monthly billing reports do not match service volume by DOS • Common complaints (re billing reports) • Not enough detail to know “why” collections are “low” • No feedback loop for QI

28. Strategies for Management Reports To match DOS & Payment Results – plan “lag time” into reports. Examine report options from billing system (it may be able to let you choose DOS) or export to Excel & get custom reports. Test ideas with small “ad hoc” pulls and /or with case review

29. Collections Rate & Fee Schedule(Common Pitfalls) Focus on “% of billed charges collected alone does not tell a useful story. Find payer mix, relation to Medicare, & reasons for variation.

30. Missing Data: Denial Reason Codes • Need to develop a list – inclusive but not limited to codes used by payers. • Do not mix denials with write-offs or copays not collected

31. Case Examples(Why we need to look at details)

32. Recommended Action Steps(Joint work with billing team) Review current reports & reporting capabilities of system Include analyst who can help export data & develop reports Document all process steps – question them, and ID options Develop shared principles & processes – how do fee schedules get set? How do denials get prioritized? Feedback loops? First review ad hoc data / then develop reports. Develop goals for USING the reports (joint goals/joint process)

33. Reporting Suggestions

34. Summary • Billing requires expertise; “facts” change/interpretations vary. • Bringing forward cases & questions is helpful • A focus on “good” documentation (enough & just right vs. more is better) helps in many ways • Reports can help tie together information from front end service and back in billing results • Feedback loops & relationships are critical to joint learning to improve effectiveness.

35. Billing Professionals: Resources Medicare Part B Newsletter http://www.partbnews.com/ State Medical Society American Medical Society http://www.ama-assn.org/ CPT Assistant Newsletter American Academy of Professional Coders http://www.aapc.com/

36. Additional CAPC Resources • Billing Tools: • http://www.capc.org/tools-for-palliative-care-programs/billing/ • Tools for Financial and Strategic Planning: http://www.capc.org/tools-for-palliative-care-programs/finance/ • Billing and Coding E-learning Course: http://campus.capc.org/PalliativeCareCourses/BillingandCoding

37. Question & Answer Period Thank you for joining us today! ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Located at Mount Sinai School of Medicine, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious, complex illness.

38. Continue the Discussion on CAPCconnectTM Forum! At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum! Go to: http://www.capc.org/forums to post your message and comments in the “Billing and Finance” discussion topic!