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Coding and Reimbursement Pearls

 

Behavior Modification Counseling Pearls (Top)
Emergency Physicians encounter wide varieties of illness and high levels of acuity every shift in the ED. Opportunities to intervene in chronic yet equally damaging medical dilemmas such as tobacco, alcohol and substance abuse also arise on a daily basis. The 2008 Current Procedural Terminology (CPT) service codes now include new Risk factor Reduction and Behavior Change Intervention codes that allow providers to separately report and bill for the time they spend engaged in such counseling.

The Behavior Modification Counseling Codes include the following requirements:

  • the service should be provided face-to-face;
  • be performed by the physician or other qualified health care provider;
  • utilize a standardized evidence-based screening tool, a specific validated intervention tool, to assess readiness to change and barriers to that change (e.g. AUDIT, DAST, SBI; please refer to the 2008 CPT Manual, pages);
  • advise change in the behavior;
  • provide specific suggested actions;
  • arrange for services and follow up;
  • be well documented (i.e. a copy of the tool should be retained in the medical record)

The Behavior Modification Counseling Codes:

  • Can be billed separately from standard ED visit codes as long as the counseling and intervention process is distinct from the ED Evaluation and Management service.
  • Cannot be billed by the emergency physician if another healthcare provider does the work and is not in the same group or employed by the emergency physician.

The Codes are:

99406 (0.24  work RVUs) Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 (0.50 work RVUs) Intensive, greater than 10 minutes
99408 (0.65 work RVUs) Alcohol and/or substance (other than tobacco) abuse structured screening (eg. AUDIT, DAST), and brief intervention (SBI) services 15 to 30 minutes.
99409 (1.30  work RVUs) Greater than 30 minutes

Medicare will cover these services when reported utilizing the newly created G Codes, G0396 and G0397. Third party payer coverage should be verified locally.
Many patients' only exposure to this intervention may be in our emergency departments. Let's not lose the opportunity to help them stop their addiction.

Critical Care (Top)
Next time you evaluate a sick patient, consider Critical Care services. This underused code requires physician documentation of the time spent directly with unstable or potentially unstable patients. Time spent documenting, reviewing labs and radiographs, and speaking with medical staff also counts. Time spent on separately billable procedures, like CPR, doesn't. You must have provided at least 30 minutes of services to bill.

Critical Care - Part Deux (Top)
There are codes you may use in addition to critical care (99291). CPT bundles certain separately identifiable services into the codes for critical care. The bundled codes are included in the list below:

  • the interpretation of cardiac output measurements (CPT 93561, 93562)
  • chest x-rays (CPT 71010, 71015, 71020)
  • pulse oximetry (CPT 94760, 94761, 94762)
  • blood gases, and information data stored in computers (CPT 99090)
  • gastric intubation (CPT 43752, 91105)
  • temporary transcutaneous pacing (CPT 92953)
  • ventilatory management (CPT 94656, 94657, 94660, 94662)
  • vascular access procedures (CPT 36000, 36410, 36415, 36540, 36600)

Any procedures not on this list can be billed separately.

Electronic Medical Record (EMR)/Electronic Health Records (EHR) (Top)
The catch phrase of our times is to 'go green'. One way the ED can lead in this arena is through the development and implementation of an electronic medical record (EMR)/electronic health records (EHR).  

A well-designed EMR should:

  • improve operational efficiency and reduce overall operational costs through elimination of transcription, document routing, document filing, paper and storage of paper;
  • prompt providers to thoroughly document the patient encounter;
  • improve overall documentation, coding and billing efficiency;
  • minimize compliance risk while supporting appropriate, optimal billings;
  • provide a searchable data base for statistical information and knowledge management to benchmark and improve the quality of care.
  • Not include templates that encourage documentation of history, and physical components that are not actually performed [see bullet two]

EMRs are still evolving and there is no perfect prototype to date. There are both templated and open-ended systems to develop a chart format based on customized client criteria. Ease of implementation varies dramatically depending on the chart design, prior ED computerization, record flow, actual time required to document the record and quality of training provided. Good planning and patience with the process are keys to success. Dividends from EMR implementation will outweigh all costs in time, effort and money.

Key considerations for the selection and implementation of EMRs are:

  • Obtain provider buy-in for the EMR before contacting vendors
  • Request trial demonstrations of different EMRs - test the documentation time required for triage, nursing and MD staff and/or obtain comparative data on time requirements
  • Get references and talk with other clients before signing a contract
  • Identify /select product and design that will be user friendly for all medical record users such as providers, coders, and billers
  • Obtain user input/feedback throughout EMR development and implementation;
  • Identify an on-site EMR specialist to serve as the liaison for the providers/users and the EMR vendor
  • Obtain comprehensive, quality training to support providers throughout the implementation process and beyond - in all but the smallest of institutions on-going system customization and training new staff as old ones turn over is a full time need
  • Consider transitional learning curve and the potential impact on initial documentation, coding, and billing efficiency
  • Interfacing with existing hospital electronic systems
  • Require a comprehensive education and orientation to all providers including all end users prior to implementation
  • National certification of approved EHRs
  • Extra staffing during implementation phase as throughput will be affected by the learning curve

The bottom line is EMRs have arrived and are here to stay! We all need to support their evolution to the betterment of our patient care, practices, and hospital partners.

Additional information and resources on EM Informatics 


Emergency Department After-Hours Code (Top)
Tired of working night shifts? For 2006 a new code is available to report services provided in the ED after 10 pm. Patients presenting to the ED between 10 pm and 8 am may have code 99053 reported in addition to the standard 99281-99285 emergency department levels of service.

 


Hospital Observation Services (Top)
Emergency Medicine Revenue Source: Observation. Remember, Observation is not a place, it is a status! If admission is a foregone conclusion, write for a full Admission, not Observation. The decision process is whether to Admit to inpatient status, admit to 23hr Observation, or Discharge home. Unlike Medicare's payment for physician observation services, Medicare's Hospital reimbursement for observation covers only three conditions: chest pain, CHF and asthma.

 


In House Codes (Top)
Did you know that in house responses are billable? Just deliver a copy of your SOAP note, or your CPR/procedure note, along with a copy of the patient's demographics, to your coders. If the attending requested you to assess a patient, be sure an official consult order is in the chart, and for Medicare document that a practicioner to practicioner request occurred. Also for consults document 3/3 past history elements for sicker patients, and document time spent.

 


Laceration Repair (Top)
These high RVU procedures are categorized as Simple, Intermediate, or Complex. Remember that not all single layer repairs are automatically considered simple. If the wound is heavily contaminated and requires "extensive cleaning or removal of particulate matter" a one layer repair may be reported as Intermediate.

 


The Level 5 Caveat (Top)
The definition of 99285 includes the concept that the History, Physical Exam, and Medical Decision Making requirements must be met "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". Most Medicare carriers require a description of the patient's urgent condition and the physician's thought process. So make sure to document why the severity of your patient's illness precludes performing a full History or Exam.

 


Level of Service (Top)
Remember, you don't get reimbursed for what you do, you get paid for what you document! A frequent deficiency area for down coding a Level 5 to 4 is the ROS. Level 4 requires 2 - 9 systems with Level 5 requiring 10+. Listing of pertinent positives and/or negatives with the statement 'all other ROS negative' meets Level 5 requirements.


Medicare's Teaching Physician Guidelines (Top)
Emergency Physicians, engaged in teaching interns, residents, fellows (IRF) and medical students as part of the attending's clinical practice, must satisfy unique requirements in order to qualify for reimbursement by Medicare.  Specific rules govern the documentation of the history and physical exam, as well as any procedures that are performed.

Does this matter to me? 

  • If you are a physician who sees patients with a medical student, intern, resident or fellow and you want to be paid, it does.

For Evaluation & Management (E/M) services, the teaching physician (TP) must be involved in the care of the patient by: 

  • personally performing the entire service independently from an IRF; or
  • having the IRF render the service and discussing it with them, but also independently performing, at minimum, the "key portions" of the service; or
  • having the IRF render the service and discussing it with them, and also being directly present (ie. in the same exam cubicle), at minimum, when the "key portions" of the service are performed by the IRF.

What can medical students do? 

  • Medical students are limited to gathering certain aspects of History:  Past, Family, Social History, and Review of Systems.

What must I document for a TP E/M? 

  • At a minimum, you must personally document that you were physically present for or performed the "key portion" of the service and that you participated in the management of the patient. (Be sure to check the ACEP website for documentation examples minimally acceptable to Medicare.) 
  • Your documentation must include a legible signature or an electronic signature that is password protected, and it must also include the date.

What is the "key portion" of patient treatment? 

This is defined by you, the teaching physician, but is susceptible to retrospective appraisal on audit.    Determination of "key portion" should be based on the clinical aspects of the case (eg. presentation, diagnosis, level of service, etc.) and the competency of the particular IRF.

What about time-based services such as Critical Care? 

  • For the reporting of time-based services, such as critical care or moderate sedation, the teaching physician must be directly present during the entire reported time period.

What about procedures? 

  • For procedures taking longer than 5 minutes the Teaching Physician must be directly present for at least the "key portions".
  • If the procedure will take less than 5 minutes to perform, the Teaching Physician must be directly present for the entire procedure.

For additional information on Teaching Physicians see the Teaching Physicians Frequently Asked Questions and the CMS policy transmittal on the ACEP website.

 


Moderate (Conscious) Sedation (Top)
Are you aware that 2006 CPT includes new codes for sedation services provided by the ED physician solely or in support of another provider such as an orthopedist? Fill out your hospital conscious sedation forms and submit these to your coders to document the necessary information to bill for these services. Moderate Sedation codes include an initial code for the first 30 minutes of intraservice time, continuous time from meds given until your personal contact ends, and a code for every 15 minutes of intraservice time thereafter. 

 


Physical Exam (PE) Requirements (Top)
Examine the Exam! All ED patients must be examined to be coded and billed. According to Medicare Documentation Guidelines a minimum of one body part is required for even the lowest ED E/M code 99281. A 99284 PE typically *requires five to seven body areas or organ systems, while a 99285 requires eight organ systems to be examined. Only organ systems may be used to satisfy the requirements for 99285.
*see ACEP FAQ on Evaluation and Management (E/M) Documentation Requirements 


HAC and POA Pearl (Top)  

Hospital Acquired Conditions (HAC) and Present On Admission (POA) are a pair of terms influencing hospital reimbursement these days. On October 1, 2008, payers began reducing or eliminating inpatient reimbursement for a variety of hospital acquired conditions. Coders and reimbursement staff are querying physicians about conditions not clearly documented as present in the ED prior to admission.

ED physician documentation is crucial to support whether or not a condition was present at the point of hospital admission.  Some key ED documentation opportunities include:

  • Infections or complications of urinary catheters, dialysis ports and PICC lines;
  • Infections of integumentary, genitourinary, respiratory systems;
  • Sepsis;
  • Staged decubitus ulcers;
  • Context of injuries (e.g. falls);
  • Adverse drug effects and reactions;
  • Interpretation of abnormal lab values (e.g. blood glucose, PTT and electrolytes).

While rule out, suspected and probable conditions can not be coded for the professional component, these differential diagnoses are valuable for the inpatient coded record. Your HPI, ROS, PMH and Clinical Impression documentation are more important than ever to support reimbursement for your hospital partner.

 


Observation Services (Top) 

When lack of diagnostic certainty (such as a head injury) or some additional therapeutic treatment (think asthma) could prevent an inappropriate inpatient admission consider Observation services. Observation is not a place, but a status and requires an admit to OBS order, periodic reassessments, and a short discharge plan/summary. There are no longer any diagnosis limitations. When disposition is uncertain, consider admit to OBS. The RVUs are higher; the outcome may become diagnostically clear.  

For additional information on Observation see the Frequently Asked Questions at: 


Medicare Resources (Top) 

In the past several years, the Centers for Medicare and Medicaid Services (CMS) has published updates to coverage decisions through their MedLearn format. This information provides a reference for many topics relevant to emergency medicine.

With implementation of the new Medicare Administrative Contractors (MACs), many changes to the way you interact with Medicare will be taking place. The Medicare website is a valuable source of news and information regarding Medicare processes and changes in your specific practice location. Log on to their website for additional information. Click on the links below to find specific information regarding your contractor and any changes taking place. 

http://www.cms.hhs.gov/MLNProducts/ 

http://www.cms.hhs.gov/MLNMattersArticles/ 

http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip* 

 http://www.cms.hhs.gov/MedicareContractingReform/01_Overview.asp#TopOfPage 

*It is recommended that you insure your system is protected when opening any zip files.


FAST Exam Pearl (Top) 

Focused Assessment with Sonography for Trauma (FAST) exam is an increasingly valuable tool for many EPs, but the documentation and coding requirements are often misunderstood. There is no single CPT code that captures the components of a typical FAST exam. Most FAST exams consist of two distinct US exams, limited cardiac (93308) and limited transabdominal (76705). Documentation should clearly reflect two separate and distinct exams. Some providers may also perform a limited chest US (76604) to evaluate for hemo/pneumothorax. Performance of the respective components of the FAST exam will of course depend upon the circumstances of the patient's clinical presentation/progression. Code for the components that were performed and documented.

Well documented US exams performed in the ED typically include several elements:

Indication- an explanation of why the study was being performed (i.e. Blunt trauma, penetrating trauma, hypotension, abdominal pain)
Interpretation-- written and maintained in the patient record, describing the organ/area studied and the findings.
Image Retention-- images must be stored and archived for future review.

Simply documenting FAST "normal" or "negative" would not meet typical documentation requirements.

Furthermore, it should be clear who performed the exam.

For additional information, please reference the ACEP Ultrasound FAQs at the following link: www.acep.org/practres.aspx?id=30502 

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