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Medical billing and coding: Achieving success

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Chiropractic manipulative treatment (CMT) Pre-manipulation assessment including: ... Work not included in the CMT includes: Review of additional or new data; ... – PowerPoint PPT presentation

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Title: Medical billing and coding: Achieving success


1
Medical billing and codingAchieving success
2
Objectives
  • Identify BWCs payment methodologies.
  • Discuss new strategies to facilitate appropriate
    bill payment.
  • Show the importance of understanding and
    providing medical documentation specific to BWC.

3
Provider Fee Schedule Current methodologies
  • Hospital inpatient services Diagnosis Related
    Groups (DRG) reimbursement system
  • Level I HCPCS codes Resource Based Relative
    Value Scale (RBRVS) methodology
  • Level II HCPCS codes Historical and third-party
    payer data/recommendations from professional
    associations.
  • Ambulatory surgical centers Nine payment groups
    identified by Medicare  
  • Outpatient hospital services Cost to charge
    ratio (CCR)   16

4
Provider Fee Schedule Payment rate comparisons
  • Professional services
  • In general, BWCs rates are similar to workers
    compensation payments in other states.
  • Comparable to Pennsylvania higher than
    California, Florida and West Virginia
  • BWCs payments are substantially higher than
    Medicare.
  • 22 CPT codes accounted for 50 of total payments
    to physicians
  • Payments for these services averaged 133 of
    Medicare and ranged from 116211 of Medicare

5
Provider Fee Schedule Payment rate comparisons
  • Ambulatory surgery centers
  • BWCs rates are similar to workers compensation
    payments in other states.
  • Comparable to Florida (some higher, some lower)
  • Lower than Pennsylvania
  • Higher than West Virginia
  • BWC pays 133 of Medicare on average.

6
Provider Fee Schedule Payment rate comparisons
  • Inpatient hospital
  • BWCs DRG rates are similar to workers
    compensation payments in other states.
  • Slightly lower than California (115 vs. 120)
  • Comparable to Pennsylvania
  • Higher than West Virginia
  • BWC pays at 115 of Medicare.

7
Provider Fee Schedule Payment rate comparisons
  • Outpatient hospital
  • BWCs rates are similar to workers compensation
    payments in other states.
  • Comparable to Pennsylvania (some higher, some
    lower)
  • Higher than Florida and West Virginia
  • BWCs payments are difficult to compare to
    Medicare rates since the payment methodologies
    differ.

8
Provider Fee Schedule 2008
  • HCPCS Level I and II
  • Fee schedules (professional and supplies)
  • ASCs
  • Payment groups
  • Inpatient Hospital
  • DRGs
  • Outpatient Hospital
  • Cost to charge ratio 16

9
Provider Fee Schedule Coding requirements
  • Effective Oct 1, 2007, BWC will recognize the
    2008 version of the International Classification
    of Diseases (ICD-9-CM).
  • Effective for dates of service beginning Jan. 1,
    2008, BWC will recognize 2008 HCPCS Level I,
    Level II, and Level III codes.

10
National Provider ID (NPI)
  • BWC will continue to accept bills containing only
    BWC legacy (or current) numbers, as well as bills
    with both the legacy number and NPI.
  • Verify information with BWCs provider relations
    department.
  • Phone (614) 644-6292, option 3 then 0
  • Fax (614) 621-1333
  • MailBWC Provider Enrollment
    P.O. Box
    182031

    Columbus, OH 43218-2031

11
NPI
  • BWC will process both CMS-1500 forms and UB-04
    and UB-92
  • Electronic version of CMS-1500 has increased
    number of diagnosis code accepted to eight.
  • You can find line-by-line instructions in chapter
    4 of BWCs Billing and Reimbursement Manual
    online.

12
Clinical editing
  • Bills validated to meet health-care industry
    coding standards
  • MCOs required to use nationally recognized
    guidelines
  • Consistent with expected results

13
15K Medical-Only Claim Program
  • 1K Program Claim is medical only with date of
    injury (DOI)
  • 5K Program Claim is medical only with DOI
    June 30, 2006, and
  • 15K Program Claim is medical only with DOI
    Sept. 10, 2007
  • Participating employers will notify providers

14
15K Medical-Only Claim Program
  • MCO does not manage claim or reimburse for
    services.
  • Bill employer directly for services related to
    injuries covered by the program.
  • Pay all bills within 30 days of receipt as billed
    or according to prior agreement with medical
    provider.

15
Grievance hearing
  • Procedure allows a provider, employer or employee
    to grieve a disputed bill payment, including
  • Grievances involving a providers objection to
    the denial of payment or reduced payment
  • Appeals regarding the recovery of overpayments.
  • It does not address BWC fee schedule grievances
    or alternative dispute resolution (ADR) issues.

16
Explanation of benefits (EOB) 776
  • Payment made for a non-allowed, related condition
  • Supporting medical documentation needed to
    substantiate determination to override and pay
    the bill

17
Appropriate use of EOB 776
  • Treatment authorized by MCO based on Miller
    Criteria for condition not specifically allowed
    in the claim, but related to the allowed
    condition.
  • Injured worker develops a post-operative
    infection which may resolve within a few weeks.
  • Injured worker develops post-operative
    complications, such as deep vein thrombosis or
    pulmonary embolism, which could require
    re-hospitalization
  • IW develops complications related to treatment
    for the allowed conditions i.e. adverse reaction
    to the medications

18
Appropriate use of EOB 776
  • Treatment not requiring prior approval is
    provided and billed with a non-allowed ICD-9.
  • Symptoms indicating that further diagnostic
    studies are necessary to determine if a more
    extensive work-related injury (than previously
    believed) has occurred.

19
Inappropriate use of EOB 776
  • The condition is expressly denied in the injured
    workers claim.
  • The MCO note does not document that Miller
    Criteria has been met.

20
Inpatient hospitalizations
  • BWC reimburses with a version of the Medicare DRG
    system. BWC implemented this process beginning
    Jan. 1,2007.
  • Approximately 6,000 inpatient bills per year
  • Hospital reimbursement and review staff
  • Includes a certified coder

21
Inpatient hospitalizations
  • Documents necessary for the review process
    include
  • History and physical
  • ED report (if applicable)
  • Operative note (if applicable)
  • Discharge summary or progress notes if stay is
    more than 48 hours
  • Discharge note if stay is less than 48 hours.

22
Inpatient hospitalizations
  • BWC recognizes correct coding guidelines for DRG
    reimbursement.
  • Regardless of allowed condition, coding should
    reflect medical record documentation of the
    treating physician.

23
Medical documentation policy E-learning
  • BWC Learning Center External User Quick Tips
  • What is the BWC Learning Center?
  • It is a Web-based application that can be
    accessed here www.bwclearningcenter.com.

24
Medical documentation policy E-learning
  • To search for or enroll in a learning event
    using the BWC Learning Center, follow these
    instructions.
  • Visit www.bwclearningcenter.com.
  • Click First Visit.
  • Enter your (or your employers) BWC policy
    number, your first name and last name.
  • Enter a login ID and a password of your choice.
  • Click Submit.
  • Complete a User Profile.

25
Medical documentation policy E-learning
  • If your name is entered in the system, you will
    be directed to contact BWC.
  • E-mail BWCLearningCenter_at_bwc.state.oh.us.com
  • Phone 1-800-OHIOBWC, option 2, 2, 2
  • To update your user profile, follow these
    instructions.
  • From the home page, click User Information
    Center.
  • Click Student Records.
  • Click Update Profile.
  • Edit as needed.
  • Click Submit to save changes.

26
Medical documentation policy E-learning
  • To enroll in a learning event, follow these
    instructions.
  • From the home page click on the Learning Center
    building/icon.
  • Click on Course Information Enrollment.
  • Search by keyword, entering a word(s) that is
    closely related to the desired training event.
  • Click Search.

27
Medical documentation policy E-learning
  • To enroll in a classroom learning event, follow
    these instructions.
  • From the returned list, locate the desired course
    and click on the information icon.
  • In the lower right section of the screen, locate
    the date/location of your choice.
  • Click Enroll.
  • If you have given an e-mail address, you will
    receive an e-mail confirming your enrollment.

28
Medical documentation policy E-learning
  • If you have no e-mail address, you will receive a
    fax or letter.
  • Once you are enrolled, you can view your list of
    selected classes (and cancel, if needed) in the
    Personal Learning Center, which is located on the
    left side of the home page.
  • To take an online learning event, follow these
    instructions.
  • From the returned list, locate the desired online
    course and click on the title.
  • Click Take Course.

29
Medical documentation policy E-learning
  • To access the Personal Learning Center, follow
    these instructions.
  • On the left side of the home page, click on
    Personal Learning Center.
  • The list will display current learning events
    (classroom session enrollment and online tutorial
    stated).
  • Click the Transcript tab.
  • Locate the learning event (classroom or online)
    you have completed.
  • Click on Certificate.
  • A survey will open if required for completion of
    the learning event.
  • When certificate displays click the Print icon to
    print it.

30
Documentation
  • Evaluation Management (EM) services
  • EM services are primarily the same as CMS rules
    with changes instituted for BWC purposes.
  • Only one EM service per injured worker per day
    will be reimbursed.
  • Credit given for additional effort required to
    treat a new injury or revise return-to-work
    restrictions.

31
Documentation
  • Established patient
  • Injury or worsening of the condition that causes
    a repeat office visit requiring a more thorough
    evaluation
  • May include an injured worker with a new injury,
    though the injured worker, based on accepted
    terminology, is considered an established patient

32
Documentation
  • Social history
  • This criterion could be met by a thorough
    occupational history.
  • Its often necessary for documentation of
    causality and return-to-work restrictions. 

33
DocumentationExamination
  • Either 95 or 97 EM guidelines exam criteria
  • 95 body areas and organ systems elements
  • 97 bullet system
  • Most favorable to provider

34
DocumentationMedical decision making
  • Number of diagnoses or management options
  • Return-to-work restrictions
  • Are essential in the management of injured
    workers
  • Are valued as a part of management option
  • May increase the complexity of management
    decisions.

35
DocumentationMedical decision making
  • Amount and/or complexity of data to be reviewed
  • BWC administrative forms completed during a visit
    are
  • Counted as a data element
  • Worth two points, regardless of the number of
    forms.

36
DocumentationTime
  • Additional time may be considered in the
    selection of the EM code if documentation
    indicates
  • Requirement to complete forms or
  • Counseling injured worker regarding
    return-to-work restrictions.

37
DocumentationTelephone calls (99371-99373 CPT )
  • May be reimbursed
  • Must be medically necessary
  • Must contribute to overall care of the injured
    worker
  • Supporting documentation with a brief description
    of the conversation noted

38
DocumentationTelephone calls (99371-99373 CPT )
  • Codes are not to be used
  • In addition to consultation services
    (99241-99255) or team conferences (99361 and
    99362)
  • For conversations with an MCO or BWC
  • As a replacement for face-to-face interaction
    with the injured worker.

39
DocumentationTelephone calls 99371
  • Simple or brief most calls will fit into this
    category
  • May be used when a provider calls the injured
    worker for
  • Consultative reasons
  • Medical management
  • Coordinating medical management with other
    health-care professionals.

40
DocumentationTelephone calls 99371
  • Discussion with the employer regarding an injured
    workers status
  • Test and/or laboratory results
  • Clarify or alter previous instructions
  • Integrate new information from other health
    professionals into the medical treatment plan
  • Adjust therapy, report on progress of treatment
  • Return-to-work status and job restrictions

41
DocumentationTelephone calls 99372
  • Intermediate telephone call
  • To discuss and evaluate new information
  • To provide details or to initiate a new plan of
    care
  • Covers at least 20 minutes of provider time

42
DocumentationTelephone calls 99373
  • Complex or lengthy telephone calls
  • Lengthy, emergent counseling session with an
    anxious or distraught patient
  • Detailed or prolonged discussion with family
    members regarding a seriously ill patient
  • Rare occurrence and required at least 30 minutes
    of provider time.

43
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44
Medical documentation
  • Sept. 15, 2005 Established patient
  • CC - Right knee pain
  • 40-year-old male presents with right knee pain
    after tripping over an extension cord at work
    (K-Mart stockroom) yesterday. He is now
    experiencing moderate to severe pain. States he
    has no numbness or tingling in the lower leg, but
    says he has a large bruise on the back and side
    of his knee. He is in good health. He has an
    occasional cigarette.
  • Patient is alert and oriented. Vital signs are
    normal. Gait is abnormal as he cannot bear weight
    on the right leg. There is a large bruise on the
    posterior and lateral aspects of the knee. There
    appears to be some effusion. He is very tender to
    palpation. Straight leg raise is difficult to
    assess due to pain. Sensation is intact.
  • Knee pain with possible ACL tear. Will request
    MRI. Rx-DarvocetN 100mg q 6 hrs prn pain. Will
    call patient to schedule MRI when we receive
    approval.

45
Medical documentation
  • History
  • Chief complaint
  • History of present illness
  • Brief one to three elements
  • Extended four or more
  • Review of systems
  • Exam
  • 95 or 97 guidelines

46
Medical documentation
  • Medical decision making
  • Diagnoses or management options
  • Data
  • Risk

47
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48
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49
Documentation
  • Type of history
  • Type of exam
  • Complexity of medical decision making
  • Established patient two/three key components
  • CPT code selected

50
Documentation
  • Osteopathic manipulation therapy (OMT) coding
    guidelines
  • Pre- and post-manipulation assessment
  • Pre-service work includes
  • Reviewing previously gathered clinical data
  • Initial or interim history
  • Reviewing the problem list.

51
Documentation
  • OMT coding guidelines
  • Pre-service work includes
  • Pertinent correspondence or reports
  • Prior care
  • Review of imaging and other test results, test
    interpretation
  • Care planning
  • Other important findings.

52
Documentation
  • An EM service may be billed on the same day as
    OMT.
  • It must be significant and separately
    identifiable from OMT.
  • CPT modifier 25 is used.
  • Examples include
  • First visit at which a patient is examined
  • Significant change in the injured workers
    condition warrants an additional evaluation
  • Change of medications
  • Review of additional or new data
  • Ordering of laboratory imaging studies, X-rays or
    additional studies.

53
Documentation
  • Chiropractic manipulative treatment (CMT)
  • Pre-manipulation assessment including
  • Reviewing previously gathered clinical data
  • An initial or interim history
  • Reviewing the problem list
  • Pertinent correspondence or reports.

54
Documentation
  • CMT
  • Pre-manipulation assessment including
  • Prior care
  • Review of imaging and other test results, test
    interpretation
  • Care planning
  • Other important findings.
  • Outcome or response to treatment must be
    included.
  • The plan for ongoing care is noted.

55
Documentation
  • CMT
  • You may bill EM on the same day as CMT.
  • The service must be significant and separately
    identifiable service.
  • Modifier 25 is appended to the CPT code.

56
Documentation
  • CMT
  • Examples of EM service billed on same day as CMT
    include
  • First visit at which time injured worker is
    examined
  • Significant change in injured workers condition.
  • Work not included in the CMT includes
  • Review of additional or new data
  • Ordering of laboratory imaging studies, X-rays or
    additional studies.

57
Documentation
  • Physical, occupational and massage therapy
    documentation
  • Must support CPT code submitted
  • Amount of time submitted for time-based physical
    and massage therapy codes
  • Inclusion of plan of care
  • Flow sheet of modalities and exercises with
    treatment
  • Short narrative of function and status with
    summary of response

58
DocumentationTime-based guidelines
  • Record time in the medical record, including
  • Beginning and ending time of the treatment
  • Time spent delivering each service.
  • Time calculations for multiple procedures
  • More than one CPT code billed during calendar
    day, total number of units billed is constrained
    by total treatment time.
  • 24 minutes of 97112 and 23 minutes of 97110 were
    furnished, total treatment time 47 minutes.
  • Three total units can be billed for treatment
    two units of 97112 and one unit of CPT code
    97110.

59
DocumentationUnits reported
  • One unit 8 minutes to
  • Two units 23 minutes to
  • Three units 38 minutes to
  • Four units 53 minutes to
  • Five units 68 minutes to
  • Six units 83 minutes to
  • Seven units 98 minutes to
  • Eight units 113 minutes to

60
Documentation
  • Do not bill for services performed less than
    eight minutes.
  • Multiple time-based procedures duration of any
    procedure is less than eight minutes and total
    treatment time exceeds eight minutes, figure time
    into total treatment time on that date.
  • Time starts when therapist is working directly
    with injured worker.
  • Do not count pre- and post-delivery services.
  • Intra-service care begins when therapist or
    physician is directly working with the injured
    worker.
  • Injured worker should already be in the treatment
    area and prepared to begin treatment.

61
Documentation
  • Time counted is the time the patient is treated.
  • Example
  • Gait training requires both therapist and an
    assistant, or even two therapists, to manage in
    the parallel bars.
  • Each 15 minutes the patient is being treated can
    count as only one unit of CPT code 97116.
  • You should not bill the time an injured worker
    spends not being treated.

62
Documentation
  • Psychotherapy
  • Insight oriented, behavior modifying and/or
    supportive psychotherapy refers to
  • Development of insight or affective
    understanding
  • Use of behavior modification techniques
  • Use of supportive interactions
  • Use of cognitive discussion of reality
  • Any combination of the above to provide
    therapeutic change.
  • Note face-to-face time spent during
    psychotherapy in the medical record.

63
Documentation
  • Submit procedure code that most closely matches
    face-to-face time spent with injured worker.
  • For example CPT codes
  • 90804 20 to 30 minutes up to and including 44
    minutes
  • 90806 45 to 50 minutes up to and including 74
    minutes
  • 90808 75 to 80 minutes up to and including 94
    minutes

64
  • Questions?
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