Government Shutdown on Medicare

government_400The governments fiscal year begins from October 1st and runs through September 30th meaning the 2014 fiscal year begins on Tuesday, October 1st, 2013. Typically during that time,  Congress is required to pass and the President sign appropriations bills that will release funds needed for the federal government to operate.

As of today, none of the 12 appropriations bills that will fund the government for the 2014 fiscal year, have been signed into law. What this means as of now, and at midnight tonight, that the government has no funds available to pay salaries of federal employees, grants, and other utilities for government operations. Congress is debating approving what is called the “Continuing Resolution” or CR. It is a legislation that will extend the 2013 fiscal year for a length of time agreed upon by Congress and the President to continue operations. Currently the length of time for a CR is unspecified. It can be one day or a CR can be extended up to a full year.

There is a possibility that Congress and the President will not reach a resolution on the adoption of the Continuing Resolution by midnight. If Congress and the President fail to reach a resolution, the result will be that all “non essential” federal employees will be told not to show up for work tomorrow, October 1, 2013.

Questions were raised that If a government shutdown occurs, will this also effect Medicare processing claims for payment for anything sent after October 1? The answer to that question is – “No”. The funds appropriated for Medicare benefits are not subject to the appropriations process because it is an entitlement program instead of a discretionary program, and processing of Medicare claims is considered “essential”. The Center for Medicare and Medicaid Services (CMS) announced that there should be no disruption of Medicare claims processing and all CMS activities will continue regardless of a delay in the appropriations process.

 

 

 

 

Prolonged Services

1314902_medical_doctorAll evaluation and management (E-M) service codes have a time value in conjunction with expanded problem focused history and medical complexity decision making. But occasionally providers will spend longer periods of time with patients but that extra time doesn’t justify coding to a higher level E-M code. To code a higher level E-M, not only does the time of a face-to-face encounter have to increase, but the complexity of medical decision making, problem focused history and counseling of care level must also increase.

The CPT manual shows two categories of codes that can be used as add-on codes to E-M codes when face-to-face time with a patient goes beyond the normal specified time values for each E-M code. The categories are outpatient/office for your typical clinic setting and inpatient/observation for hospital/Skilled Nursing Facility (SNF) patients.

99354 – 99355 – Outpatient/office

99356 – 99357 – Inpatient/Facility

Encounter Time –

Understanding what the CPT manual specifies as encounter time will help with knowing how to use and assign the prolonged visit codes. In an office/clinic setting, the encounter time is defined as face-to-face spent with the patient by the provider or practitioner. This time includes time spent on history review, obtaining records, performing the exam and counseling the patient. Activities performed before and after the face-to-face time are not included as part of the face-to-face time.

For example, a patient seen in a office/outpatient setting, a provider spends 15 minutes reviewing medical records and history, the spends 30 minutes face-to-face time with the patient, then spends another 20 minutes coordinating care with staff or other providers. The encounter time here is the 30 minutes that was spent face-to-face with the patient. The additional 35 minutes is not counted towards the actual encounter time.

When services are provided in an inpatient/facility setting, encounter time is defined as the time the physician/practitioner is present on the patients facility unit and at the patients bedside rendering services for that patient. This time also includes, medical record review, examining patient, encounter documentation, orders, communication with other professionals and patients family.

The additional time that must be spent with a patient in order to use the prolonged visit add on codes is 30 minutes. If a professional spends 25 additional minutes with the patient, then they cannot use the add on codes. The minimum time spent to qualify for the add on codes is 30 minutes and extends to 60 minutes. If the encounter time surpasses 75 minutes, a second add on code can be used. The encounter time for the prolonged visit codes is the same for both the outpatient/office setting and inpatient/facility setting.

Example:

Setting                               First Hour                    Add’l 30 minutes

Office/outpatient …………. 99354 ……………………. 99355

Inpatient/facility …………… 99356 ……………………. 99357

The encounter time does not have to be continuous. Blocks of time can be added together to account for the total encounter time. For example, a physician or practitioner spends time with a patient, goes to see another patient, then returns to the first patient, those separate times with the first patient can be added together for the total encounter time. However this time does not include staff time. Time is only counted by the physician/practitioners face-to-face time with the patient.

The prolonged visit add on codes are to be used in addition to the traditional E-M codes. The E-M codes are still the primary codes used for exams. So an example of the prolonged visit codes in conjunction with the E-M codes would work like this,

A provider sees an established patient in an office setting and determines the exam uses low medical decision making complexity and a problem focused history which supports a E-M code of 99213. A encounter lasts a total of 55 minutes and is not dominated by counseling or coordination of care. The CPT manual specifies encounter time of 15 minutes for a 99213, so the encounter has gone 40 minutes longer than the specified 15 minutes for the 99213. So the physician can add on the prolonged visit code of 99354 to be billed with the 99213. The same example can be used with the inpatient/facility setting using the corresponding E-M facility codes.

The prolonged service codes can be used in conjunction with all the typical E-M codes. The times will just need to be adjusted to qualify for the add on. So for a 99214, the CPT manual specifies 25 minutes for encounter time. So the total time will have to reach 55 minutes to use the add on codes.

Documentation –

Patients medical records must indicate the duration of the prolonged service. It must also show that the physician/practitioner personally provided the time specified in the code definition. The medical record should also show the total encounter time of the visit. Total time can represent the total face-to-face time in minutes, or the start and stop time of the visit. It should also be notated as to why the encounter was prolonged.

Prolonged services can provide providers with additional reimbursement for lengthy encounters but should be documented appropriately to show total time and reasoning for the prolonged service so as to withstand audit or review.

 

 

Expanding Payment Channels

DollarsAs the industry grows and changes at a rapid pace, more and more provider offices are becoming increasingly  concerned at the increase in patient responsibility. Employers are continually looking for ways to save money on increasing healthcare costs. In order to save and still offer employees healthcare coverage, many employers are moving to higher deductible plans leaving patients to pay more out of pocket. As patient responsibly continues to rise, patients are having more influence in the payment process to providers. By expanding payment channels, providers will be able to collect more payments effectively.

83 percent of providers surveyed said it took longer than 30 days to collect payments from patients after insurance carriers paid claims.

Patient Interaction – A key factor in facilitating payments is to make attempts to collect payments at any interaction point with patients. When scheduling appointments, calling for prescription refills, diagnosis followups, lab results etc., notify patients they have outstanding payments due and begin the process of collecting.

Technology – 72 percent of patients prefer to pay bills online. It is estimated in 2016 consumers will spend $300 billion online. The ability to take payments online is another key factor in increasing payment collection from patients. Website and online access give patients a 24/7 ability to go online and make payments without the need for staff interaction.

Cultural – Training staff to prepare and enable them to collect payments more frequently is another factor in increasing revenue. implementing tools and policies such as prompt pay discounts, staff incentive programs, minimum payment requirements, and scripts to assist them when interacting with patients are other effective ways to collect revenue.

Expanding payment channels will assist with better management in revenue cycle and lowering the aging of accounts.