Post on 12-Nov-2014
description
3/13/2010
1
SPECT Myocardial Perfusion Imaging - 36 % cut
Transthoracic echo with spectral and color flow Doppler 10 % cut Coronar Stent 4 % c t
Slide 2
Coronary Stent - 4 % cut EKG - 5 %cut Consults eliminated by CMS APC for Remote interrogation
of implantable cardiovascular monitor is reassigned reimbursement from $771 to $38
THE SKY IS FALLING …. THE SKY IS FALLING …
$38 Equipment Utilization impacts
practice expense formulas◦ Cardiac MR / Cardiac CT
3/13/2010
2
STOP◦ Playing the game by the wrong rules
Slide 3
◦ Playing the game by the wrong rules◦ Providing FREE CARE◦ Adopting the wrong approach to denial management◦Under estimating the TEAM approach◦ Limiting technology to claim submission
Slide 4
Document what was doneDocument why it was doneWhen appropriate – speak CPT
3/13/2010
3
The accuracy of CPT coding on the provider’s part unfortunately cannot guarantee payment
The RulesSlide 5
p y g p yby all payers and plans. Providers must review the coding and coverage policies of each individual carrier with whom they are contracted.
Copyright 2010, Coding Strategies, Inc.
Medicare Guidelines◦ Existing consultation codes will not be covered
Slide 6
g(99241 – 99255) Primary or Secondary claims◦ Report outpatient ‘consults’ as Office Services New / Established ( 99201 – 99215 ) Has the patient been seen within 3 years? Documentation guidelines differ New – Est.
Copyright 2010, Coding Strategies, Inc.
3/13/2010
4
◦ Report inpatient ‘consults’ as Hospital Inpatient Services
Slide 7
Initial (99221-99223) for initial patient encounter Modifier AI admitting physician of record)
Subsequent evaluation during the same admission (99231 – 99233)
◦ Cross-walk … 5 levels of consults into 3 levels of Hospital Initial Inpatient Services Documentation documentation Documentation .. .documentation …
Copyright 2010, Coding Strategies, Inc.
Slide 8
Copyright 2010, Coding Strategies, Inc.
3/13/2010
5
CPT 76376◦ 3D rendering with interpretation and reporting of
Slide 9
computed tomography, magnetic resonance imaging, ultrasound, or other tomographicmodality; not requiring image postprocessing on an independent workstation
◦ CPT 76377i i i i ; requiring image postprocessing on an
independent workstation
Copyright 2010, Coding Strategies, Inc.
4 cardiac MRI codes that previously included flow/velocity quantification (75558, 75560, 75562, 75564) deleted
Slide 10
CPT Description75557 Cardiac MRI for morphology and function wo contrast;75559 ..with stress imaging75561 Cardiac MRI for morphology and function wo contrast, followed
by contrast material and further sequences;75563 …with stress imaging
Velocity flow mapping (75565) may be used in conjunction with any cardiac MRI codes – once per encounter
+75565 Cardiac MRI for velocity flow mapping (list separately)
Copyright 2010, Coding Strategies, Inc.
3/13/2010
6
Coronary Interventions Peripheral Interventions
Slide 11
e p e a te e t o s Cervical Carotid Interventions
◦ Diagnostic angiography/venography separate?◦ Catheterizations separate?◦ Imaging separate?
Copyright 2010, Coding Strategies, Inc.
Diagnostic angiography/venography separately reportable if:◦ No prior catheter-based angiography/venographic study is
available
Slide 12
available ◦ a full diagnostic study is performed and the decision to
intervene is based on the diagnostic study A study is available, but …◦ The patient’s condition with respect to the clinical
indication has changed since the prior study, OR◦ There is inadequate visualization of the anatomy and/or
pathology ORpathology, OR◦ There is a clinical change during the procedure that
requires new evaluation outside the target area of intervention
Copyright 2010, Coding Strategies, Inc.
3/13/2010
7
Via transseptal puncture, ablation catheter into the left atrium
Ring of lesions is created at the ostium of each
Slide 13
Ring of lesions is created at the ostium of each affected pulmonary vein
TIME CONSUMING procedure (6+ hrs)
Report service with SVT ablation code (93651) Carriers may instruct to use unlisted code
(93799)( ) Modifier -22 may be utilized for physician
claims◦ Do more than just send in the report
Copyright 2010, Coding Strategies, Inc.
Slide 14
Copyright 2010, Coding Strategies, Inc.
3/13/2010
8
“One of the top billing
Slide 15
One of the top billing errors determined by federal, state and private payors involves the incorrect use of modifiers.”
Copyright 2010, Coding Strategies, Inc.
“Increased Procedural Services”
Slide 16
Parenthetical notes define criteria for code as Increased: Intensity Time Technical difficulty Severity of PT condition Severity of PT condition
Copyright 2010, Coding Strategies, Inc.
3/13/2010
9
Slide 17
Copyright 2010, Coding Strategies, Inc.
Q: What would be the correct way to code the following scenario?
Slide 18
A patient presents with atrial flutter or atrial fibrillation. Right atrial pacing cannot be performed because the arrhythmia cannot be paced. Right ventricle pacing/recording is not performed. Pacing and recording from the coronary sinus are done to assist in mapping the arrhythmia. Once the arrhythmogenic focus is mapped and ablated, programmed stimulation and pacing is performed in an attempt to induce the arrhythmia.
Copyright 2010, Coding Strategies, Inc.
3/13/2010
10
… Because the right atrium could not be paced, and the right ventricle may not have b d d d d Alth h th
Slide 19
been paced and recorded. Although the procedures described in the add-on codes 93621/93623 were done, a full comprehensive study was absent.
A: To use the add-on codes, a base code must first be reported and if all the elements of afirst be reported, and if all the elements of a comprehensive are not done, then modifier 52, Reduced services, is appropriate. (93620-52).
Copyright 2010, Coding Strategies, Inc.
However, it is usually proper to perform a complete study once a sinus rhythm is obtained after
d bl f l fl d
Slide 20
cardioversion or ablation for atrial flutter and fibrillation. This is to ensure that there is not a hidden accessory pathway or another problem. If atrial and ventricular pacing is done before or after the ablation, the code for a complete EP study can be reported. Whether the induction of arrhythmia is successful is irrelevant because the code describessuccessful is irrelevant, because the code describes the attempt at induction, not the success of the procedure, and supports the use of code 93620.
CPT Assistant October, 2008 Q&A
Copyright 2010, Coding Strategies, Inc.
3/13/2010
11
Procedure was set up, patient came down and was prepped for an EP study. 12-lead
Slide 21
p pp yshowed no arrhythmia and the decision was made to give IV Isoprel.
Option 1 – report the infusion (approx $125) Option 2 – 93620-(discontinued 53/73) (50% of
the APC rate or approx. $1700)
Copyright 2010, Coding Strategies, Inc.
Designed to reduce errors due to clerical entries and incorrect coding.“ h li f l i i dj di t d t l i t
Slide 22
“..each line of a claim is adjudicated separately against the MUE of the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of a MUE CPT modifiers such as -service in excess of a MUE. CPT modifiers such as 76, -77, -91, and -59 will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.
Copyright 2010, Coding Strategies, Inc.
3/13/2010
12
Fluoroscopic guidance can be reported by both the
Slide 23
be reported by both the physician and the facility –when documented
CPT®
CodeDefinition
71090 Insertion pacemaker, fluoroscopy andradiography radiological supervisionradiography, radiological supervisionand interpretation
Copyright 2010, Coding Strategies, Inc.
Importance of clinical history◦ Medical necessity◦ Signs and symptoms or
Slide 24
Signs and symptoms, or◦ Confirmed diagnosis
Documentation of procedure:◦ Complete description of technique◦ Identify ancillary services such as mapping and ICE◦ When a diagnostic procedure is performed followed
by a therapeutic procedure describe the sequence ofby a therapeutic procedure, describe the sequence of events including the decision to perform the therapeutic service
Copyright 2010, Coding Strategies, Inc.
3/13/2010
13
Right heart catheterization and atrial and ventricular angiography (93501, 93529-
Slide 25
g g p y ( ,93533, 93539, 93543, 93555) are integral components of percutaneous transcatheter closure of septal defect and should not be reported separately.
Echocardiography (including transthoracic, transesophageal, and intracardiac) may be reported separately.
Copyright 2010, Coding Strategies, Inc.
Do not rely on the coding team ◦ Can’t abstract what wasn’t documented
Slide 26
◦ Can’t confirm what was done was documented
Clinical staff – providers and non-physician staff need to understand CPT guidelines for the top procedures
Copyright 2010, Coding Strategies, Inc.
3/13/2010
14
Slide 27
Understand Medical Necessity – the carrier’s versionCommunicate Medical NecessityExpect patient participation and share of cost(s)
Copyright 2010, Coding Strategies, Inc.
Health plans deny service◦ 47% … not medically necessary
Slide 28
◦ 23% lack information to approve coverage◦ 17% are non-covered services
Do not assume all plans under the same payer are equal◦ Employers exclude services and/or conditions to◦ Employers exclude services and/or conditions to
reduce medical expenses
Copyright 2010, Coding Strategies, Inc.
3/13/2010
15
Slide 29
Copyright 2010, Coding Strategies, Inc.
Be familiar with evidence-based clinical guidelines
Slide 30
g◦ Confirm which guidelines are used by the health
plan(s)◦ Submit documentation clearly stating the reason(s)
for the requested service Because it was ordered … Because the patient needs it …. Why is this path of treatment better than the next What is unique with this patient’s care that needs to be an
exception to the rule
Copyright 2010, Coding Strategies, Inc.
3/13/2010
16
Slide 31
Copyright 2010, Coding Strategies, Inc.
Slide 32
Copyright 2010, Coding Strategies, Inc.
3/13/2010
17
Slide 33
Copyright 2010, Coding Strategies, Inc.
Slide 34
Copyright 2010, Coding Strategies, Inc.
3/13/2010
18
Slide 35
Copyright 2010, Coding Strategies, Inc.
Slide 36
Copyright 2010, Coding Strategies, Inc.
3/13/2010
19
Slide 37
Copyright 2010, Coding Strategies, Inc.
Slide 38
Copyright 2010, Coding Strategies, Inc.
3/13/2010
20
Slide 39
Copyright 2010, Coding Strategies, Inc.
Most often used for:◦ Exam ordered for a
Slide 40
Exam ordered for a condition that is not covered under the Medicare LCD
◦ Screening Studies
E bj t t◦ Exam subject to frequency limitations.
Copyright 2010, Coding Strategies, Inc.
3/13/2010
21
Slide 41
More than resubmitting a claimThink Dandelions
Copyright 2010, Coding Strategies, Inc.
All services are coded correctly All modifiers are assigned correctly
Slide 42
All services are preauthorized correctly Medical necessity is clearly explained simply
with ICD-9 codes All carrier requirements are met consistently All systems are programmed correctlyy p g y Insurance carriers pay for all services
performed Pigs fly
Copyright 2010, Coding Strategies, Inc.
3/13/2010
22
1) Recipient not eligible on DOS2) Recipient has other insurance coverage
Slide 43
3) Past filing time w/o acceptable documentation4) NDC missing or invalid5) Duplicate claim6) Procedure code / age conflict7) Service is bundled into another service8) Service is not covered8) Service is not covered9) Procedure requires preauthorization10) Lack of medical necessity
Copyright 2010, Coding Strategies, Inc.
Working denials to be paid? Working denials to get it off my desk?
Slide 44
Working denials to improve the process?◦ Consider the feedback /communication ◦ Consider tracking mechanisms – education
Think Dandelions!
Copyright 2010, Coding Strategies, Inc.
3/13/2010
23
Appeals Alert!
Highmark Medicare Services Appeals department isHighmark Medicare Services Appeals department is seeing numerous requests for Monitored Anesthesia Care (MAC) where the diagnosis does not meet the medical necessity requirements outlined in the Local Coverage Determination (LCD). Please double check your medical documentation against the requirements outlined in LCD L27489 prior to requesting a redetermination Remember to report diagnosis codesredetermination. Remember to report diagnosis codes that are supported by the medical documentation.
Effective January 1, 2010 … sort of◦ CMS will delete the edit retroactively but not until
April 1st
Slide 46
April 1
Copyright 2010, Coding Strategies, Inc.
3/13/2010
24
Working denials means understanding◦ Coding conventions
Slide 47
g◦ Medical framework of the procedures◦ Communication skills needed to speak to multiple
audiences
◦ IR cases◦ EP studies – not the typical mix of services must be yp
appealed – with more than the report
Copyright 2010, Coding Strategies, Inc.
An add-on code is used for ICE:
Slide 48
Appropriate for specific base CPT codes; otherwise, ICE may be reported using an
CPT® Code Definition
+93662(-26) Intracardiac echocardiography during therapeutic/diagnosticintervention, including imaging supervision and interpretation (Listseparately in addition to code for primary procedure)
, y p gunlisted procedure code (93799)
Copyright 2010, Coding Strategies, Inc.
3/13/2010
25
The mapping codes can be reported in conjunction with:
Slide 49
◦ Comprehensive EP study (93620)◦ Ablation of arrhythmogenic focus (93651-93652)
Only one mapping code can be reported for each encounter◦ If both were done, report 3D mapping
Do not apply modifier 26 to 3-D mapping for professional component billing
Copyright 2010, Coding Strategies, Inc.
Slide 50
Copyright 2010, Coding Strategies, Inc.
3/13/2010
26
Slide 51
Copyright 2010, Coding Strategies, Inc.
Understand the patient’s coverage Understand the carrier’s meaning of medical necessity
h l d
Slide 52
Gear the letter to your audience Explain beneficiary’s condition◦ Make the patient a real person facing a difficult
situation◦ Impact of the condition of patient’s life without the
treatment◦ Describe the alternative treatments that have been◦ Describe the alternative treatments that have been
considered Explain how the treatment will reduce risk for further
treatment
Copyright 2010, Coding Strategies, Inc.
3/13/2010
27
Maintain an appeals resource file◦ Template letters for frequently challenged
Slide 53
gprocedures
Persistence pays off“ Keep appealing. It may take more than one
appeal to reverse a health plan’s incorrect denial. When a procedure or service has been appropriately performed, documented and pp p y p ,reported, be persistent to ensure your practice obtains the proper compensation based on the negotiated health plan contracted rate. “ AMA Practice Management Center
Copyright 2010, Coding Strategies, Inc.
◦ “Appeal of a Medical Necessity or Experimental / Investigational Adverse Determination”
Slide 54
Investigational Adverse Determination 90 days from date of notice (denial) Anthem acknowledges within 5 days of receipt Request for information must be received within 10
days Reviewed by specialist in same or similar specialty not
involved in initial review Resolution letter within 30 days◦ Request for external review is also an option
Copyright 2010, Coding Strategies, Inc.
3/13/2010
28
Slide 55
Specific forms for appeals / reconsiderations State specific forms
Copyright 2010, Coding Strategies, Inc.
Slide 56
Training – education –Feedback –I’m just a “ x “
Copyright 2010, Coding Strategies, Inc.
3/13/2010
29
Communication between provider and coding staff is a critical component
Slide 57
p◦ Routine opportunities to discuss issues Protocols in conflict with coverage guidelines Discuss procedures – medical necessity
Communication within the coding staff is a critical component◦ Eliminate the need for staff to hoard information◦ Eliminate the need for staff to hoard information
Copyright 2010, Coding Strategies, Inc.
Illustrate for each employee how they impact the real bottom line.
Slide 58
PATIENT CARE
Accept the diversity in work style, motivation, and adapt wherever possible
Cl l id tif Th C t d d Clearly identify The Customer and respond accordingly
Copyright 2010, Coding Strategies, Inc.
3/13/2010
30
Slide 59
Analysis (RAC) data miningInternal Edits / AuditsNatural language processingWeb based learning
Copyright 2010, Coding Strategies, Inc.
Learn the rules ◦ Educate the key stakeholders
Slide 60
Perform internal review of coding /documentation / denials◦ Identify opportunities to improve dictation –
revenue◦ Don’t pick the weeds – eliminate ‘em
Evaluate the team◦ Best fit for each task◦ Best fit for each task◦ Accept the hard task if necessary
Maximize the technology available
Copyright 2010, Coding Strategies, Inc.
3/13/2010
31
Slide 61
Your Presenter:Karna W. Morrow
Coding Strategies, Inc.Karna.Morrow@codingstrategies.com