This ACOInformation series on practice management issues has been created in response to member requests for information that will help you more effectively manage your practice. The series is prepared by the ACOI Clinical Practice Committee. ACOI members are invited to suggest areas for discussion in the series.
- The Importance of Accurate Coding and Billing
- Joining a Physician Group
- Teaching Physician Documentation Guidelines
- ICD-9 Coding Required October 1
- OIG 2004 Work Plan: Key Monitoring Areas
- Claims Processing Tools for Physicians Practices
Coding and billing for health care services provide the basis for physician reimbursement. Coding systems are a means of communicating to third-party payers exactly what was done to or for a patient by the physician and why the service was provided. Correct utilization of the codes will help the practice receive, in a timely manner, the full reimbursement allowed for work performed by the physician. Correct coding and documentation will also prevent charges of fraudulent billing that can result in significant fines, penalties and jail time for the physician.
CPT codes tell the insurance carrier what service was provided to the patient and determine the amount of reimbursement. Accuracy in documentation of services performed and choosing the correct code is important. For example, if you coded a 99212 (level II visit) and your documentation supports a 99213 (level III visit), not only is this considered fraudulent billing, but you also were reimbursed $15.16 less (per Medicare) than you should have earned. Diagnosis codes tell the carrier why a service was provided and determine whether that service will be paid or denied. Certain services are payable only for certain diagnoses. If a covered diagnosis is not provided, the service is denied.
Modifiers give the carrier additional information to use when processing the claim. For example, modifier 50 indicates a bilateral procedure and increases the payment amount. Modifier 25 added to the office visit or consultation code tells the carrier the E&M service is not bundled into the procedure billed on the same day and allows separate payment for visit/consult.
To assist in coding accuracy, practitioners need to avail themselves of a variety of educational opportunities. These include:
- Coding and compliance training for all new physicians;
- Coding tools to assist the physician in accurate coding;
- Annual coding audits and utilization review with feedback to the physicians;
- Comparison of coding to national norms ( see chart);
- Review of coding reports with feedback to staff.
The accompanying chart (download chart) illustrates the normative billing practice for primary care visits versus a sample individual group. Clearly, opportunities exist to improve coding and reimbursement. Many groups continually audit, monitor and educate physicians on proper coding and revenue enhancement, such as getting reimbursed for patient counseling, nursing home calls, etc. In addition, on an on-going basis, practice managers should monitor changes by specialties and inform the physician members of these changes to stay on top of approved coding and billing issues. Another good source for coding and billing information is from your specialty societies.
Please contact our ACOI staff if you have any questions or suggestions.
It is always difficult making an employment decision when there are so many different opportunities presented at once. Considering whether or not to join a physician group or which group to join can be confusing. Besides compensation and benefits, there are many other variables to consider.
Variables to consider are:
- what are my responsibilities?
- what potential growth is there in the group?
- will I have a say in decisions made by the group?
- what is the compensation package?
- do they invest in newer technology?
- is there security in the group?
- what is the administrative involvement?
- is there a restrictive covenant in the contract?
- what is the call rotation?
- at how many sites would I have to practice?
- where do I want to live and where is the job located?
- what is the quality of the school district if you have children?
It depends on what stage in your life you are at and what is important to you at the time of your job search. If you are a new physician just coming out of training, it is highly recommended to bring employment opportunities to someone you trust. One of the best sounding boards would be one of your teachers, a knowledgeable mentor. They should have worked in the medical field and know some of the landmines to watch for. Always have an attorney review any kind of employment agreement. You need to be aware of what you are committing yourself to. All physician groups offer a compensation package. This is where many variables come into play. When looking at compensation, ask yourself, is it a guaranteed income? If so, for how long and what happens after the guarantee runs out? Are you paid on production? If so, is production compensated on collections, or a formula of relative value units (RVUs)? Is administrative time compensated? Are there expected performance standards, such as number of office visits and hours that have to be met? What happens if you don’t meet those standards? All physician groups will charge an overhead rate. Is the overhead a fixed percentage, is it based on actual expenses you use, is it market driven, can it be changed at any time? Don’t be afraid to ask these questions for clarification. If needed, ask for the clarification in writing so that you will have something to reference in the future. The benefit package. What kind of pension plan does the group have? Is it a contributory plan, 401K, tax sheltered annuity? At times it is difficult to take advantage of the tax free contributions, but it is highly recommended to save what you can. Health and dental is another major benefit to look at. What is the coverage and deductible? Is it an HMO or a PPO? Is a cafeteria (so-called IRS 125) plan available that allows you to personalize your benefits? What other benefits does the organization have? If the group does not offer a benefit plan, obtain quotes on coverage prior to making your decision. The cost of the coverage may surprise you.
Another area of concern is legal protection. What is the malpractice coverage? Is it enough coverage for your specialty and area? Who pays for malpractice? Who is responsible for tail coverage? Does the physician group have a compliance plan to protect you as an employee? Is the physician group meeting the federal regulations, such as Stark and HIPAA? As you can see, there are a lot of difficult questions to be answered. As mentioned above, talk with your teacher/mentor. Check with an attorney before signing anything. Some of our leadership have been asked in the past to assist in reviewing contracts. We have and will continue to do so to provide assistance to the physician. Contact the ACOI office for further information; however, any help we may provide does not eliminate the need for an attorney’s review. Take the time to gather all the facts. It is important to look at the TOTAL employment package before making any employment decision.
There have been recent clarifications by Medicare regarding Teaching Physician (TP) documentation guidelines. Some physicians may not be following the Medicare teaching physician documentation guidelines. Medicare continues to audit teaching physician documentation. Inadequate documentation can result in significant fines and penalties from the Office of the Inspector General.
The TP is required personally to document the following: a) that they performed the service or physically were present during the key or critical portions of the service when performed by the resident; and, b) their participation in the management of the patient. You should not submit a bill for a service if the TP is not physically present.
These are examples of unacceptable documentation:
- “Agree with above.”
- “Rounded, Reviewed, Agree.”
- “Discussed with resident. Agree.”
- “Seen and agree.”
- “Patient seen and evaluated.”
- A legible countersignature or identity alone.
Such documentation is not acceptable because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.
The following documentation examples are taken directly from the Medicare Carriers Manual. You should ensure that your documentation follows one of the examples listed below.
Acceptable Documentation
“I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.” “I saw the patient with the resident and agree with the resident’s findings and plan.” “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
The ICD-9-CM diagnosis codes must be included on all Medicare electronic and paper claims billed to Part B carriers effective October 1, 2003. If the diagnosis code is not included, carriers will return the claims as unprocessable.
Carriers will no longer place invalid or valid diagnosis codes on the claims. Carriers also will not enter missing diagnosis codes on claims for mammography screening, flu and pneumonia shots. The codes must be entered by the submitter.
Regarding diagnostic laboratory and certain other services, “the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner,” according to federal law. A laboratory or other provider must report on a claim for Medicare payment the diagnostic code(s) furnished by the ordering referring physician/practitioner.
If the physician does not supply the code, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering/referring physician’s narrative diagnostic statement or seek diagnostic information from the physician. A laboratory or other provider, however, may not report on a claim for Medicare payment a diagnosis code in the absence of physician/practitioner-supplied diagnostic information supporting such code.
According to carrier instructions, when a physician or provider submits a claim to a Medicare Part B carrier, they must assign an ICD-9-CM code to the service as follows:
- Coding When Diagnosis is Known
Assign an ICD-9-CM code that provides the highest degree of accuracy and completeness. In the past, there has been some confusion about the meaning of “highest degree of specificity,” and in “reporting the correct number of digits.” In the context of ICD-9-CM coding, the “highest degree of specificity” refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis. Concerning level of specificity, ICD-9-CM codes contain either 3,4 or 5 digits. If a 3-digit code has a 4-digit code that further describes it, then the 3-digit code is not acceptable for claim submission. If a 4-digit code has a 5-digit code that further describes it, then the 4-digit code is not acceptable for claim submission. - Coding When Diagnosis is Unknown
Diagnosis documented as “probably,” “suspected,” “questionable,” rule-out,” or “working diagnosis,” should not be coded as though they exist. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit such as signs, symptoms, abnormal test results, exposure to communicable disease, or other reason for the visit. (See ICD-9-CM Official Guidelines for Coding and Reporting, page 49, available at http://www.cdc.gov/nchs/data/icd9/icdguide.pdf.) For the complete carrier instructions, go to http://cms.hhs.gov/manuals/pm_trans/B03046.pdf.
Q. What will the government be monitoring in my practice in 2004?
A. The Department of Health and Human Services' Office of the Inspector General (OIG) recently released its work plan for 2004. Following are some of the key areas on the hit list.
Consultations
OIG investigators are scrutinizing the appropriateness of physician consulting services. The Medicare carrier's manual specifies criteria for the use of a consultation code:
- A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation);
- A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record; and After the consultation, the physician prepares a written report of his/her findings for the referring physician.
Coding for Evaluation and Management (E&M) Services
OIG will identify providers with "disproportionately higher volumes of high-level E&M codes." Physician practice groups, if they are not already doing so, should analyze their providers' E&M services against national data or Medicare's bell curve to determine outliers. Once outliers have been determined, the practice should then perform a medical record review to determine whether providers' documentation support the level of service billed.
Use of Modifier 25
OIG will determine whether modifier 25 is being used appropriately in situations where the provider performed a procedure and E&M on the same date of service. Beware - the current procedural terminology (CPT) codebook definition and Medicare guidelines differ.
Modifier Usage with National Correct Coding Initiative Edits
OIG is looking for improper usage of modifier 59 "distinct services," which would allow payment for a service that would normally be bundled into another.
Place-of-Service Errors
Since Medicare pays higher for services performed in a physician office, OIG plans to review whether physicians properly coded the place of service on claims for services provided in ambulatory surgery facilities.
Care Plan Oversight
Care plan oversight occurs when the physician supervises home health and hospice agencies in the care of beneficiaries who need complex, multidisciplinary care. Due to the increase in charges from 2000 to 2001, OIG will be looking to see that those services were provided according to Medicare regulations. Proper documentation is the key to billing those services.
The AOA is one of 17 national medical associations that make up the National Medical Specialty Health Insurance Coalition (NMSSHIC). The group’s combined membership totals more than 500,000 physicians. NMSSHIC regularly meets with the American Association of Health Plans (AAHP) to discuss issues of common interest.
As a result of these meetings, a number of working groups were formed including one on claims processing. The claims processing work group includes members of NMSSHIC, representatives of health plans and hospitals. The claims processing work group’s mission was to identify ways that health plans and providers could improve the efficiency of the claims processing system. The group developed three tools to address the claims processing problems encountered in physicians’ practices. A brief summary and description of the tools follows.
Improving Claims Processing and Payment: A Self-Assessment Tool for Providers
Claims are frequently delayed because of incomplete and inaccurate information on the claims submission form. The self-assessment tool, in the form of an easy to use checklist, is intended to assist physicians to take steps necessary to improve claims processing and payment and to increase administrative efficiency. Download form
Coordination of Benefits: Tips for Reducing Payment Delays and Improving Accounts Receivable
Claims are often delayed because of the lack of information necessary to coordinate benefits. Reasons for coordination of benefits (COB) delays include: incomplete or inaccurate COB information on file with the plan or provider, and failure to attach the explanation of benefits (EOB) from the primary payor when billing the secondary payor. The one page “tip sheet” was developed to inform physicians and their office staff about steps they can take to reduce COB related claims delays. Download form
Claim Correction Form
Often it is necessary to resubmit claims because of additional information or documentation. Resubmitted claims are sometimes coded as duplicates and rejected. The claim correction form was developed because many health plans prefer receiving a claim correction form instead of an additional claim. The form can be filled out online and sent as an email attachment to payors or printed and faxed to them. Download form