“Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA...
Transcript of “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA...
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Practice Management:
“ShowmetheMoney…!!
VikramArora,MD,MPHAssociateDirector
HeritageValleyFamilyMedicineResidency
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Agenda
• ReviewTop5CommonTopicsonBoards– CodingandBilling– MedicarerulesandregulaGons– HIPAAetcetc.– MalpracGce– DischargingpaGentsfromyourpracGce
• TopicReview…BoardQuesGons
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• ABFM– FewquesGonsrelatedtoPracGceManagement– MostlyrelatedtoMedicareandMalpracGce
• AOA– MorePracGceManagementquesGons– Varietyoftopics
WhydoIcare…
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WhydoIcare…
$158,000–averagemedicalschooldebt
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CodingandBilling
• CommonProceduralTerminology(CPT)fromtheAMAoutlinescriteriaforeachcode
• EachofficevisitwillhaveaCPTforEvaluaGonandManagement(E&M)services
• LevelofinvolvementofapaGentencounter
– AndmayhaveaddiGonalprocedure(CPT)codesforproceduresperformedonthepaGent(modifiers)
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CodingandBilling• Howyoucodedictateswhatyouwillgetpaid!• OfficevisitshavefiveE&Mcodinglevels
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$30-40 $60-90 $100-130
WELLVISITSANNUAL$150-180
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CodingandBilling
• AddiGonaly….isthepaGentanewpaGentorestablishedpaGent?(ad'saddiGonal$20-40)
– NewpaGentifnotseenwithinthelast3yearsinyourpracGce
– EvenifyouarethePCPontheirinsurance,theyarenewifnotseenwithinthelast3years
• Modifiers–25,50etc.
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HospitalVisits
• IniGalandsubsequentvisitsgofromalevel1whichisstraightforwardtoalevel3(high-complexity)
• ConsultaGonsgetcodedfromalevel1to5
• ObservaGon/discharges• VisittopaymentGmeabout3months
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CodingandBilling
• WhichofthefollowingfactorsallowsyoutocodeatahighercomplexityforavisitbasedoncounselingorcoordinaGngcare?
a) Complexityofcareb) PresenceofpsychiatriccondiGonsc) Numberoftestsorderedd) Numberofreferralsmadee) Timespent
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CodingandBilling
• AccordingtotheCurrentProceduralTerminology,anewpaGentisonethathasnotreceivedprofessionalservicesfromthephysicianwithinthelast:
a) Oneyearb) Twoyearsc) Threeyearsd) Fouryearse) Fiveyears
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MedicareRulesandRegulaGons
• Createdin1965aspartofSocialSecurityAct• BegancoveringpaGentsin1966• Covers:– Allpersons65yearsofageandolder– Specialgroups:• Longtermdisability• ESRD
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– PartA:Hospitalcoverage• PaidforbyFICA(taxdeducGon)
– PartB:OutpaGentcoverage• premiumdeductedfromSScheck
– PartC:MedicareAdvantage– PrivateinsurersthatlocallyadministrateMedicare
– PartD:PrescripGondrugcoverage
MedicareRulesandRegulaGons
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MedicareRulesandRegulaGons
• Hospicecare:– Lifeexpectancyislessthan6months
• SkilledNursingFacility(SNF)– Typicallyneedshospitalstay(3daysormore)– Coversupto100daysinSNF
• Homehealth• Needawheelchairorwalker,specialtransportaGon• mayleavehomeformedicaltreatmentetc..
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MedicareRulesandRegulaGons
• Medicareexclusions:Х MostcarereceivedoutsidetheUnitedStates(withexcepGonsforemergenciesalongtheCanadianandMexicanborders)
Х Custodialcare,includingmostlong-termnursinghomecare
Х AnnualgynecologicexamsХ RouGnedental,eyeorfootcareХ Eyeglassesandhearingaids
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MedicareRulesandRegulaGons
• WhichofthefollowingcriteriamustbemetforapaGentcoveredbyMedicaretobeeligibleforhospice?
a) PaGenthassignedaDoNotResuscitateorderb) PaGentmustagreetoforgofuturehospitalizaGonsc) PaGentmustfirstbetransferredoutofthenursinghomed) PaGent’sprognosismustbesixmonthsorlesse) PaGent’sreferralmustcomefromhisorherprimarycare
physician
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MedicareRulesandRegulaGons
• MedicareofferscoverageforwhichofthefollowingrouGneservices?
a) Adultfostercareplacementb) EmergencyroomvisitonvacaGoninFrancec) Dentalcared) Mammographye) Hearingaids
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MedicareRulesandRegulaGons• PaGentonHospiceduetopancreaGccancerdevelopsacute
pneumoniawithrespiratoryfailureandrequesGngtohavefulltreatmentinhospital?
a) RecommendaspaGentisonhospicehecannotreceivefulltreatment
b) PrescribehimsomePOanGbioGcsc) Admithimtothehospitalacutelytomanagehispneumoniad) Heisprobablydeliriousandcannotmakeanydecisions
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No,it’snotafemalehippopotamus.Anyoneelseknow?
HIPAA
• HealthInsurancePortabilityandAccountabilityAct(1996)
• MainlyaffectsphysiciansthroughtheProtectedHealthInformaGon(PHI)area– PHIisanyinformaGonaboutanpersonspast,present,orfuturemedicalhistory,ortreatmentspluscontainspaGentidenGfierssuchasname,address,phone#’s,etc.inanyformofstorageortransmission
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HIPAA
• AlsoextendstohealthcareprovidersyettoseethepaGent
• AllhealthcareprovidersandhealthcareinsGtuGons/agenciesmustcomplywithHIPAA
• ViolaGonscanresultinfinesorsancGons
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HIPAA• WhencanapaGent’sPHIbeshared:– Theysignaconsentforreleaseofspecificmedicalrecords -or-
– TheysignaNoGceofPrivacyPracGcesandarequestforPHIfallsintooneofthefollowing:• Treatment-anotherphysicianinvolvedinthecareofthepaGent• Payment-theinsurancecompany,billingoffice• HealthOperaIons-Qualityofficer,audits
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EMTALA
• EnactedIn1986,toensurepublicaccesstoemergencyservicesregardlessofabilitytopay
• Medicare-parGcipaGnghospitalstoprovideamedicalscreeningexaminaGon(MSE)foranemergencymedicalcondiGon(EMC),includingacGvelabor,regardlessofanindividual'sabilitytopay
*EmergencyMedicalTreatmentandAc5veLaborAct
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StarkLaw
• Enactedin1989
• Itprohibitsphysicianreferralsofdesignatedhealthservices("DHS")ifthephysician(oranimmediatefamilymember)hasafinancialrelaGonshipwiththatenGty
• AfinancialrelaGonshipincludesownership,investmentinterest,andcompensaGonarrangements
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RegulaGons• WhatlegislaGoncoverstheprivacyofpersonalhealthinformaGon?a) ClinicalLaboratoryImprovementsAct(CLIA)b) EmergencyMedicalTreatmentandAcGveLaborAct
(EMTALA)c) FamilyMedicalLeaveAct(FMLA)d) HealthInsurancePortabilityandAccountabilityAct
(HIPAA)e) StarkLaw
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RegulaGons• WhichofthefollowingiscorrectregardingHIPAA(HealthInsurancePortabilityandAccountabilityAct)regulaGons?
a) PrivatephysicianofficesareexemptfromtheseregulaGons
b) PrivatephysicianofficesarecoveredbytheseregulaGonsonlyiftheyacceptMedicare
c) HospitalvolunteersareexemptfromtheseregulaGonsd) InadvertentbreachesofconfidenGalityarenotviolaGons
oftheseregulaGonse) Allhealthcareprovidersandsitesarecoveredbythese
regulaGons
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MedicalMalpracGce
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MedicalMalpracGce
• TypesofmalpracGceinsurance:
– Occurrence(25%)• CoversallincidentsthatoccurduringtheeffecGvedatesofthepolicyregardlessofwhentheywerereported
– Claims-made(75%)• CoverscaseswheretheincidentoccurredandtheclaimwasmadeduringtheeffecGvedatesofthepolicy(employment)
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MedicalMalpracGce
• TypesofmalpracGceinsurance:– Tail• CoversclaimsmadeforaperiodofGmeaKertheeffecGvedatesofthepolicy(claimsmadepolicy)
– Nose• CoversclaimsmadeforaperiodofGmebeforetheeffecGvedatesofthepolicy(occurrencebasedpolicy)
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MedicalMalpracGce
• WaystoavoidaClaimagainstyouifareguiltyofcommipngamedicalerror:
– MakecontactwiththepaGent/family– BeempatheGctowardsthepaGent/family– Candidlyexplainwhatwentwrong– Donotblameanotherphysician– Explainhowyouwilltrytomakethingsright
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MedicalMalpracGce
• WhichtypeofmedicalmalpracGceinsuranceispurchasedattheGmeofreGrementfromamedicalpracGce?
a) Claims-madepolicyb) Claims-paidpolicyc) Nosecoveraged) Occurrencepolicye) Tailcoverage
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MedicalMalpracGce• Whichoneofthefollowingistrueregardingmedicalerrors?a) MalpracGceliGgaGonismorecommonwhenphysicians
discloseerrorstopaGentsb) Theuseoftheword“error”shouldbeavoidedwhen
disclosingmistakestopaGentsc) PhysiciansinprivatepracGcearemorelikelytodisclose
errorstopaGentsthanthosephysiciansemployedbyaninsGtuGon
d) PaGentsprefertoreceiveapologiesandexplanaGonswhenamedicalerrorhasbeenmade
e) ItisethicallydefensibletoonlydiscloseanerrorifthepaGentisawarethereisaproblem
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DischargingPaGentsfromyourPracGce
• IfyouhaveneverseenapaGent,youcannotbeforcedtoseethem(atleastnotyet)
– ManypracGcesare“full”andwillnottakenewpaGents– PaGentswillhavetoselectanotherphysiciantoprovidemedicalservicesforthem
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DischargingPaGentsfromyourPracGce
ForestablishedpaGents,youcan“discharge”themfromyourpracGceaslongasyou:
1. ProvidethemwithalererstaGng:– EffecGvedateofthedischarge– Reasonyouaredischargingthem• Rudeorinappropriatebehavior• Notfollowingmedicaladvice• Failuretocometoscheduledappointments
2. ProvidecareforanaddiGonal30days
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DischargingPaGentsfromyourPracGce
• FailuretofollowthisprocesscanresultinachargeofAbandonment– Canbeonthelosingendofalargeserlement
• ItisnotAbandonmentif:– Thephysician/paGentrelaGonshipismutuallyterminated– Thephysician/paGentrelaGonshipisterminatedbythepaGent
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DischargingPaGentsfromyourPracGce
• WhenphysiciansdecidedtodischargeapaGentfromtheirpracGcetheyarerequiredtoprovidethepaGentwithwhichofthefollowing?
a) CopyofthepaGent’schartb) Reasonforthedischargec) Referraltoanewphysiciand) ReviewofthepaGent’saccounte) Emergencycareforthenext30days
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DischargingPaGentsfromyourPracGce
• WhendischargingapaGentfromamedicalpracGce,thephysicianmustprovideemergencycareforaperiodofGmesoastoavoidachargeof:
a) Abandonmentb) DiscriminaGonc) Fraudd) Mandamuse) Negligence
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Summary
• ReviewedTop5CommonTopicsonBoards– CodingandBilling– MedicarerulesandregulaGons– HIPAA,EMTALA,Stark– MalpracGce– DischargingpaGentsfromyourpracGce
• QuesGons?
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CodingandBillingPracGce
• hrp://emuniversity.com/index.html