Top Ten Coding Errors for Pediatric Gastroenterologists

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Top Ten Coding Errors for Pediatric
Gastroenterologists

• Kathleen A Mueller, RN, CPC, CCS-P, CMSCS
• ASKMUELLER Consulting, LLC
• Lenzburg, Il 62255

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10 Lack of Use of Modifier 63

• Modifier 63 to be used on all infants less than 4
  kg.
• Appropriate for procedures only. Not for use on
  diagnostic studies or visits
• Adds 25 increased reimbursement for most
  commercial payors

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9 When There Is No CPT Code

• Procedure does not quite fit definition of
  existing CPT code
• Use modifier 22 or 52, or
• Use an unlisted procedure code
• Claim must be accompanied by procedure report and
  a detailed description of what was done beyond
  the existing definitions, including time, and
  crosswalk your proposed compensation to other
  codes

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8 Place of Service Errors

• Billing place of service inpatient when should
  have been observation and vice-versa
• This is a submission error. Billers should be
  checking for the visit history in the hospital
  prior to submitting all charges.

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7 Diagnosis Code Inaccuracies

• C.E.R.T. (Certified Error Rate Testing) indicates
  that diagnosis codes submitted on the claim must
  match what is documented in the medical record or
  this is considered an error in billing.
• Train all providers to be specific with diagnosis
  codes.
• Includes all types of visits specifically
  inpatient visits. When the patients
  symptoms/conditions change, so should the
  diagnosis codes to reflect the change in billing.
  

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7 Diagnosis Code Inaccuracies

• Update all charge tickets for proper diagnosis
  codes. Educate providers on specificity and use
  of signs and symptoms
• Medical necessity and payment is based on
  complexity of decision making
• Now is the time to prepare all providers for
  ICD-10-CM which requires greater specificity in
  the assignment of diagnosis codes

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6 Medical Necessity

• The level of service billed is not supported by
  the documentation in the medical record. This is
  determined by
• History
• Examination
• Decision Making or
• Time if more than 50 of the visit is dedicated
  to counseling and coordination of care

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6 Medical Necessity

• It is essential to train all providers on the
  evaluation and management billing and coding
• http//www.cms.hhs.gov/MLNProducts/downloads/eval_
  mgmt_serv_guide.pdf
• Do self audits within the practice or hire a
  consultant(s) to perform audits and educate all
  providers.
• Utilize benchmarking by comparing national data
  to practice data

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6 Medical Necessity

• Use appropriate diagnosis codes to support the
  level of service billed. Moderate complexity
  decision making should be reflected by the
  diagnosis codes utilized.

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5 Lack of Time documentation

• Common Scenario
• Patient and family comes in for test results.
  Visit should be totally based on time spent in
  counseling and coordination of care. However,
  note looks like this
• Extensive time spent with patient and family
  discussing. This will only support
  99212 since there is no history or exam to back
  up anything.

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5 Lack of Time documentation

• Instead, the note should look like this
• The entire 45 minute visit was spent with Tyler
  and his mother going over test results. All
  questions were answered and we will proceed
  with.
• 99215 would be the proper code based on time.

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5 Lack of Time documentation

• How much time has been spent reviewing records
  before or after the visit? Was this in the
  medical record? If so, can bill
• 99358 Prolonged evaluation and management service
  before and/or after direct (face-to-face) patient
  care (eg, review of extensive records and tests,
  communication with other professionals and/or the
  patient/family) first hour (List separately in
  addition to code(s) for other physician
  service(s) and/or inpatient or outpatient
  Evaluation and Management service)

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5 Lack of Time documentation

• 99359 Prolonged evaluation and management service
  before and/or after direct (face-to-face) patient
  care (eg, review of extensive records and tests,
  communication with other professionals and/or the
  patient/family) each additional 30 minutes (List
  separately in addition to code for prolonged
  physician service)

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4 E/M Service and Procedures on Same Day

• The E/M visit is billable only if decision to
  perform procedure occurs during visit and
  documentation is above and beyond the need for
  the procedure.
• E/M service not billable prior to a scheduled
  open-access procedure.
• 25 modifier required on E/M service prior to
  minor procedure of 0-10 day global period
• 57 modifier required on E/M service prior to
  major procedure of 90 day global period

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4 E/M Service and Procedures on Same Day

• Check the Federal Register when new Medicare fee
  schedule is released. Will be released November
  25, 2009. This contains the global period
  assigned to each procedure code. Update your
  billing software accordingly.
• Just because the patient is new to the provider
  doesnt mean that a visit can be billed.

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3 Surgical Modifiers for Physician Billing 51
versus 59

• 51 Do not use unless instructed by payer. Has
  no effect on reimbursement. Not required by
  Medicare since 12-1-2002. Still required by some
  Medicaid carriers.
• 59 Used for procedures that are bundled into
  other procedure under the Correct Coding
  Initiative (CCI) edits.

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Surgical Modifiers for Physician Billing 58
versus 78 versus 79

• 58 Staged or Related procedure
• Restarts global period
• Not used to report complications
• Visits not billable prior to procedure
• Example Redo suction biopsy
• 78 Return to OR
• Complication of original procedure
• Does not restart global period
• Payable at intraoperative percentage only

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Surgical Modifiers for Physician Billing 58
versus 78 versus 79

• 79 Unrelated procedure
• Visit payable before procedure with 24 modifier
• Restarts global period
• Example
• Colonoscopy or EGD within global of suction
  biopsy.

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2 Shared Services

• Common Scenario
• Practice hires an NP or PA (NPP)
• Consultations and New Patient visits are
  scheduled with the physician
• NPP sees patient and documents History,
  Examination, and Treatment Plan
• Physician sees patient briefly and/or discusses
  patient with NPP
• Physician adds to documentation and/or co-signs
  note
• Service is billed under physicians provider
  number

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Incident to

• Included in the original CMS regulations
• Modified over time
• Applies to services provided by one person and
  billed under another

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Incident to

• To qualify as incident to, services must be
  part of your patients normal course of
  treatment, during which a physician personally
  performed an initial service and remains actively
  involved in the course of treatment.

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Shared Service

• Consultations in any location and New Patient
  Visits in the office can not be billed incident
  to even if physician sees patient after the NPP.
• Service must be billed under NPPs provider
  number
• A Shared Service is permitted for hospital
  visits other than Consultations.

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Office/Clinic Setting

• When an E/M service is a shared/split encounter
  between a physician and a non-physician
  practitioner (NP, PA, CNS or CNM), the service is
  considered to have been performed incident to
  if the requirements for incident to are met and
  the patient is an established patient.
• If incident to requirements are not met for
  the shared/split E/M service, the service must be
  billed under the NPPs NPI.

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Hospital Inpatient/Outpatient/Emergency
Department Setting

• When a hospital inpatient / outpatient or
  emergency department E/M is shared between a
  physician and an NPP from the same group practice
• And the physician provides any face-to-face
  portion of the E/M encounter with the patient
• The service may be billed under either the
  physician's or the NPP's provider number

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Hospital Inpatient/Outpatient/Emergency
Department Setting

• However
• If there was no face-to-face encounter between
  the patient and the physician (e.g., even if the
  physician participated in the service by
  reviewing the patients medical record) then the
  service may only be billed under the NPP's
  provider number.

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Split/Shared E/M Service

• CMS Manual System Department of Health Human
  Services (DHHS)
• Pub. 100-04 Medicare Claims Processing Centers
  for Medicare Medicaid Services (CMS)
  Transmittal 178 Date MAY 14, 2004
• www.cms.hhs.gov/transmittals/downloads/R178CP.pdf

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1 Consultations vs. New Patient Visits

• New Patient (99201-99205)
• A patient that is self referred
• Or referred for a procedure to evaluate a problem
• And has not received any face-to-face service by
  anyone in the practice of the same specialty for
  any reason for at least three years

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Consultations (99241-99255)

• Requires a documented request from another
  physician/NPP
• Request is for an evaluation and opinion
  regarding a problem
• Requires a separate letter back to requesting
  physician/NPP summarizing findings and
  recommendations

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Consultations - Continued

• Request should come in writing but must be
  documented in consultants chart
• Copy of chart notes does not meet requirement for
  separate letter
• Can initiate treatment or order diagnostic tests
  and still bill initial encounter as a
  Consultation
• If initial intent of referring physician is to
  transfer care or for a procedure, service is a
  New Patient/Established Patient Visit.

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When Not to bill a Consultation

• When you have been asked to do a procedure
  (insert PEG, change PEG, manage patient
  condition, do endoscopic procedure since this is
  a transfer of care)
• When you are admitting the patient since this is
  a transfer of care
• When you dont see a request from another
  provider seeking your opinion of a problem
• When the patient/guardian is seeking a second
  opinion
• When you are asked to see the patient again
  during the same hospitalization even if for a
  different problem

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Consultation Update

• Effective 1-1-2010, consultations will no longer
  be paid by Medicare. Claims will be denied.
• Updates in the Medicare websites will be done in
  the next few weeks.
• Commercials and Medicaid have yet to make any
  statements.
• New patient visits, initial hospital care,
  initial SNF visit and established patient visits
  to be billed in place of consultations

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RAC (Recovery Audit Contractors)TOP 10

• 10.Debridement Coding
• 9. Duplicate Billing-Filing claims more than
  once for the same service
• 8. Stark Violations-Physicians referring patient
  to services in which they have a financial
  interest or in which a family member has a
  financial interest

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RAC (Recovery Audit Contractors)TOP 10

• 7. Pharmaceutical Coding in Physician Offices-
  Incorrect use of codes or units in billing of
  injections
• 6. Social Work Services in Facilities- Some
  clinical social worker services provided to
  inpatients in hospitals or skilled nursing
  facilities cannot be billed under part B

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RAC (Recovery Audit Contractors)TOP 10

• 5. Psychiatric Services- Over utilization of
  psychiatric services provided in outpatient
  setting.
• 4. Medical Necessity- Documentation not
  supporting the level of service provided in the
  outpatient setting
• 3. E/M Billed During Global Periods
• 2. Place of Service Errors

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RAC (Recovery Audit Contractors)TOP 10

• 1. Incident-to Errors- Physician assistants and
  nurse practitioners performing services for a
  physician but not following billing-specific
  guidelines related to the physicians
  relationship to the patient and the physicians
  presence in the office

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Contact Information

• Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS
• ASKMUELLER CONSULTING, LLC
• askmueller_at_aol.com