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.

 

 

Improving Documentation

1314902_medical_doctorThe purpose of ICD-10 is to provide more detailed information on the care being provided. There are many steps that need to be taken in order for a practice to prepare for the ICD-10 conversion that is coming October 1, 2014. One of the key changes that will need to be made by some, if not most, physicians is what type of information is being documented in a patient’s medical records and determining whether that information is enough.

Looking at how diagnosis information is being documented will help physicians and coding staff be better prepared for the ICD-10 switch.

Here is a suggested process on how you can better prepare your documentation for ICD-10.

Pull a handful of medical records on some of your more commonly used diagnoses. Review those records with your coding staff, and have them determine if your current documentation provides enough information to associate the appropriate ICD-10 code. If it doesn’t, then you’ll know improving documentation is a necessary change for your practice.

But what kind of information are you supposed to include in your documentation to be able to code for ICD-10???

The best way to think of what the differences are between ICD-10 and ICD-9 is to think of ICD-10 as “expanded”. Most diagnoses in ICD-10 are expanded to include things like body locations, types, causes etc. Laterality is an example of what is expanded in ICD-10. So, documentation for diagnoses needs to include information on which side of the body is affected (right, left, or bilateral). Below are a few other examples of how ICD-10 is expanding on a particular diagnosis and the documentation that will need to be in the medical records.

Fractures –

  • Site
  • Laterality
  • Type
  • Location

Injuries –

  • External Cause – You will need to provide “how” the injury occurred.
  • Place of occurrence – Where did the injury take place?
  • Activity code – What was the patient doing that caused the injury?
  • External cause status – Indicate if the injury was related to another source (military, work, etc.)

Diabetes Mellitus –

  • Type of Diabetes
  • Complication or manifestation
  • Body system affected
  • If type 2 diabetes, long-term insulin use

Making your documentation as detailed as possible will help your coding staff assign the appropriate codes and help reduce the potential for rejected claims. ICD-10 shouldn’t affect patient care. All it is doing is requiring more detailed information. Most of the information is likely already being provided to you during the patient’s visit. It is just making sure you’re recording everything your coding staff will need to chose the correct code.

Improving documentation will improve coding staff turnaround time on billings and in turn reduce the amount of rejected claims for coding issues and so will help you to maintain a consistent revenue stream.

 

ICD-10

141,000!!

What is that 141,000 number mean? That is just the total number of ever more specific diagnosis codes that comes along with the Tenth Edition of the International Classification of Disease (ICD-10). A little bit of an increase from the Ninth Edition (ICD-9) which totaled 17,000 codes. The department of Health and Human Services (HHS) extended the compliance date from what would have been October 1 of this year, to October 1, 2014. Although the date has been pushed back once again, HHS urges all covered entities under the Health Information Portability and Accountability Act (HIPAA) to continue, or start, preparations for the transition to ICD-10.

A transition of this magnitude requires extensive planning and preparation in all aspects of a medical practice and throughout the industry. It is recommended that timelines be established as soon as possible to help manage tasks and keep the transition from becoming too overwhelming.

The Centers for Medicare & Medicaid Services (CMS) have created an example timeline to help illustrate the process. Click the link below to view the timeline.

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallMediumTimelineChart.pdf

What does this mean for a physician?

Most changes will be on coding and coding staff becoming familiar with the new format of codes and the multiple options for a specific diagnosis. It will also take some coordination from physicians in being more specific with their diagnosis when charting. In ICD-9 there would typically be one option for a particular condition, where as in ICD-10 there may be multiple. Below is an example of of the differences of what is reported using ICD-9 and what will be required with ICD-10.

Example: 1                                      

ICD-9

784.0 – Headache

ICD-10

G441 – Vascular Headache Not elsewhere classified

R51 – Headache

Example: 2

ICD-9

784.59 – Speech Disturbances

ICD-10

R4702 – Dysphasia

R4781 – Slurred Speech

R4789 – Other Speech Disturbances

Note: ICD-10 will not affect CPT codes.

Although diligent efforts are being made industry wide for a smooth efficient transition, a change of this scale is not without it’s bumps and hiccups, foreseen and unseen alike. Payment, and claims processing delays are a major concern. With the 5010 transition last year which was the electronic claim file format upgrade from 4010, payment and claims processing delays did cause cash flow problems nationally. Cash flow is a major concern to any organization, group, private practice or covered entity under HIPAA. To help organizations prepare as best they can and avoid cash flow issues, it is being recommended that organizations begin preparations now! Some consultants have also suggested providers and organizations build a line of credit that can sustain them anywhere from two to six months after the compliance date to manage delays in payments.

Training of coding and other staff is also a vital component for preparations for the ICD-10 transition. Studies showed that after the ICD-10 transition in Canada, staff productivity dropped by 50 percent in the first six months. A drop in productivity means that fewer patient claims will be submitted timely and more money paid to staff for increased time thus affecting cash flow and the bottom line. It is imperative that physicians and organizations help staff to understand the importance of preparing for the transition to avoid productivity drops.

Contacting vendors is also another key cog in the wheel of preparation. Contact and follow up with, EHR/EMR vendors, billing software vendors, outsourced billing providers, electronic clearinghouses, and payers. Software testing with clearinghouses and payers will typically be handled through the software vendors, or outsourced service providers but none the less, providers and organizations should follow up to ensure preparation and timelines have been established.

Some helpful hints to plan for the ICD-10 transition:

  • Start a plan
  • Establish a timeline
  • Contact vendors
  • Staff Training
  • Build a line of credit

If you’re asking yourself, “when do i start planing for ICD-10?”. THE TIME IS NOW!

 

Physician Quality Reporting System (PQRS)

stethoscope notepadThe Physician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative (PQRI), is designed to create incentives and also adjustments for eligible professionals to report quality information back to the Centers for Medicare & Medicaid Services (CMS).

For what purpose???

CMS intends PQRS to create a “quality standard” of satisfactory reporting. In doing so the hope is to lower the possibility of fraudulent claims and maximize the level of payment to providers.

Eligible professionals who successfully report the quality measures required to CMS on at least 50 percent of Medicare Part B and Railroad Medicare covered services, are eligible to receive a 0.5 percent payment incentive on their total estimated allowed charges to the Medicare Part B Physician Fee Schedule (PFS) during the reporting period (calendar year). The estimated Allowed charges of course are based on covered professional services under the PFS. Eligible professionals who do not meet the required 50 percent of the Physician Quality Reporting System during the specified reporting period, will be subject to a 2 percent adjustment of their total allowed covered charges to the PFS, meaning a 2 percent reduction in Medicare Part B and Railroad Medicare eligible payments.

To begin reporting quality measures for the Physician Quality Reporting System requires no registration or forms. Quality measures are reported to CMS on Medicare Part B and Railroad Medicare covered services one of four ways. The first (1) being on Medicare Part B and Railroad Medicare claims. The second (2) being, a qualified physician quality reporting registry. The third (3), transmission to CMS through a qualified electronic health records (EHR/EMR) software or product. Fourth (4), transmission through a qualified Physician Quality Reporting System vendor.

The Physician Quality Reporting System is in effect for 2013 for eligible professionals to receive incentive payments of 0.5 percent for successfully reporting quality measures on 50 percent of their Medicare Part B and Railroad Medicare patients in 2014. The adjustment or payment reduction of 2 percent is also in effect for eligible professionals who do not report quality measures on at least 50 percent of Medicare Part B and Railroad Medicare patients.

Physician Quality Reporting System eligible professionals include:

Physicians:

Doctor of Medicine

Doctor of Osteopathy

Doctor of Podiatric Medicine

Doctor of Optometry

Doctor of Oral Surgery

Doctor of Dental Medicine

Doctor of Chiropractic

Practitioners:

Physician Assistant

Nurse Practitioner

Advanced Practice Registered Nurse

Clinical Nurse Specialist

Certified Registered Nurse Anesthetist

Certified Nurse Midwife

Clinical Social Worker

Clinical Psychologist

Registered Dietitian

Nutrition Professional

Audiologist

Therapists:

Physical Therapist

Occupational Therapist

Qualified Speech – Language Therapist