Archive for the ‘Coding Edge’ Category

Budget cuts in education and compliance programs may be penny wise but dollar foolish.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC

Under the False Claims Act (FCA), a health care facility or entity may be held liable for the conduct of its individual employees, or even the conduct of other entities with which it contracts or associates. This holds true even where the health care facility or group practice entity has no knowledge that its employee or contracted entity engaged in the preparation or submission of false claims.

The FCA allows a private-party plaintiff (a qui tam relator or “whistleblower”) to bring suit on behalf of the United States to recover monies paid to persons or entities who submitted false claims to the government. Actions also may be brought by the government directly.

If found guilty, the offending party can be held liable for a civil penalty from $5,500 to $11,000 for each false claim submitted, as well as three times the amount of actual damage to the federal government. Where the action is initiated by a whistleblower/qui tam relator, the defendant also may be required to pay the relator’s costs and attorney’s fees. The two primary statutes relevant to these actions are 31 U.S.C. §3729, which provides the statutory basis for liability, as well as the penalties for violation; and 31 U.S.C. §3730, which provides the statutory requirements for filing of a private civil (qui tam) action, on behalf of the government, against a person or entity who is alleged to have violated 31 U.S.C. §3729.

Liability Doesn’t Require Intent

An action for making a false or fraudulent claim for Medicare or Medicaid reimbursement may be brought when: 1) a false claim (or statement in support of a claim), 2) was presented or caused to be presented to the United States, 3) with the knowledge that the claim or statement was false, and 4) the false claim caused damage to the government.

Although the FCA requires “knowing” presentment of a claim containing false material, the statute (31 U.S.C. §3729(b)) expressly states, “No proof of specific intent to defraud is required.” The statute broadly defines the terms “knowing” and “knowingly” as including “actual knowledge,” “acts in deliberate ignorance of the truth or falsity” of the information submitted on the claim, or “acts in reckless disregard of the truth or falsity of the information” submitted on the claim form. That is, knowledge is imputed (assumed) where it can be shown that the entity acted with reckless indifference or deliberate ignorance.

For example, a single physician in a multi-physician practice group routinely up-codes claims. If the practice fails to take steps to ensure the validity of the claim data, or assumes a “see no evil” approach to billing, the group could be liable under the FCA for recklessly allowing false claims submissions, or for deliberately ignoring evidence that false claims were submitted. Such allegations against the group are especially likely where the government or qui tam relator is confident that it has a better chance of obtaining payment of penalties and damages from the facility. Even in cases where the group practice is not found to have sufficient knowledge, it likely will incur legal expenses to defend itself or the targeted party.

An implied false certification claim under the FCA is based on the principle that the simple act of submitting a claim for reimbursement implies compliance with all governing rules that are a precondition of payment (Mikes v. Straus, 274 F.3d 687, 699 (2nd Cir. 2001)). Although courts have reiterated consistently that mistakes — and even negligence — are not fraud under the FCA (see Wang v. FMC Corp., 975 F.2d. 1412, 1420 (9th Cir. 1992)), there is often a fine line between what constitutes negligent conduct and what is considered reckless.

The Ninth Circuit Court of Appeals held that providers who bill Medicare have a duty to familiarize themselves with the requirements for payment (U.S. v. Mackby, 262 F.3d 821, 828 (9th Cir. 2001)). As a result, reporting in a manner clearly contradicted by statutory or regulatory payment provisions could lead to FCA liability. Where the violation pertains to a provision found in the Centers for Medicare & Medicaid Services’ (CMS) interpretive guidance, liability becomes less certain, and often turns upon whether the applicable provisions are found as a condition of payment or a condition of participation (see Mikes at 699-702).

For example, a qui tam FCA claim was brought against a physician’s group, Heart Doctors, based on the allegedly fraudulent billing of one of the Heart Doctors’ employed physicians. The facts of that case were revealed in subsequent litigation between the physician group, Heart Doctors, and the employed physician, Dr. Lane (Heart Doctors v. Lane, 2006 WL 2692694 (E.D.Ky. Sept. 13, 2006)). Dr. Lane allegedly was instructing nurses to provide chemotherapy procedures without the supervision of a physician, and then directing to bill Medicare as if the procedure had been performed in the presence of the physician. Heart Doctor’s apparently had no actual knowledge that this conduct had occurred; however, the qui tam relator brought the FCA case against Heart Doctors alleging that it recklessly permitted false claims to be submitted. Heart Doctors settled the FCA case for $434,180, and incurred over $100,000 in attorney fees.

Not only do hospitals and health care provider groups face substantial FCA liability as a result of the conduct of those that it employs, or with whom it contracts/associates, but a number of federal courts have held that there is no right to indemnification or contribution for FCA liability from either a co-defendant or from a third party where the indemnification claim is dependent on finding FCA liability by the party seeking indemnification. In other words, even if a single individual within the group is responsible for false claims, the group cannot recover the cost of defending itself and/or penalties from that individual.

As an example, Heart Doctors attempted to obtain indemnification from Dr. Lane because it was Dr. Lane’s conduct that led to Heart Doctors’ FCA liability. Citing a line of cases, the court in Heart Doctors found that a qui tam defendant cannot seek to offset their liability under the FCA through suits seeking indemnification or contribution from a third party. (See Mortgages Inc. v. U.S. District Court of the District of Nevada, 934 F.2d 209 (9th Cir. 1991); U.S. ex. Rel Madden v. General Dynamics Corp., 4 F.3d 827 (9th Cir. 1993)).

Prepare for the Perfect Storm of FCA Liability

Current and possible future conditions favor increased FCA liability for all health care providers.

As the economy worsens, physician payments are diminished, and patients — due to escalating co-payments and deductibles — avoid seeking physician services. These occurrences generally create a motive for physicians/groups to code services more aggressively.

Proposals in Congress may change provisions of the FCA to favor the qui tam relator and the government. See FCA Correction Act of 2007, S.2041 and Substitution S.2041, 110th Cong. (2007); FCA Correction Act of 2007, H.R. 4854, 110th Cong. (2007). These proposals include changes to the way that FCA damages are calculated, the addition of separate liability for the government’s costs of pursuing an FCA case, and elimination of the public disclosure original source rule that bars an FCA qui tam action where the qui tam plaintiff is not the original source of the information that leads to the filing of an FCA case. If these changes are enacted, it is anticipated that many more qui tam cases will be filed.

The Recovery Audit Contractor (RAC) program incents private contractors to find overpayments.

When combined, increased post-payment scrutiny, diminished barriers to filing an FCA case and potentially increased damages, and an incentive for more aggressive coding practices make a near perfect setting for substantially heightened FCA liability for any physician group, hospital, or other entity.

Take Steps to Limit Liability

Hospitals and physician groups make much better targets for qui tam relators (because they tend to have more money). As such, these entities must take deliberate steps to reduce FCA exposure due to the improper employee or contractor conduct. Specifically, employee and sub-contractor education in proper coding and documentation, as well as the relevant rules establishing conditions of payment, is critical. An effective internal audit program will not only identify errors before they get out of hand, but will demonstrate the entity’s efforts at compliance, thereby mitigating the potential that recklessness or deliberate ignorance can be shown.

The bottom line is this: Physician groups can be held liable directly for their own failure to prevent submission of false claims, as well as indirectly where the costs of defending such an action fall to the entity. Moreover, because indemnification is not permitted, hospitals and physician groups should consider stepping up efforts at minimizing FCA liability to preclude the possibility of such an action ever occurring. This may include reconsidering any budget reductions in the area of staff (physicians/coders) education and training, internal auditing, and compliance programs. Given the substantial amounts that can be recovered under the FCA, budget cuts in these areas may end up being “penny wise and dollar foolish.”

Use terminology, order placement, and coding guidelines to accurately capture these specialized services.

By David B. Dunn, MD, FACS, CIRCC, CCS, CCC, CPC-H, RCC

Arterial catheter placement is a ubiquitous part of interventional radiology, cardiology, and endovascular surgery, and affects both facility and physician coding. Because it is such an important part of these specialty procedures, choosing the correct placement codes is essential for accurately capturing the physician’s services, ensuring proper reimbursement, and maintaining compliance.

Learning specific codes for any individual artery is not necessary because there are so many named vessels, and coding can vary for the same vessel depending on the access site, approach to the vessel, and variant anatomy. For example, a superficial femoral artery (SFA) selection is a first order placement for an antegrade approach with an ipsilateral common femoral access but is a third order placement for a contralateral approach (up and over the bifurcation of the aorta).

For a physician to meet the minimum documentation requirement, it’s imperative for the documentation to include all locations used to gain access into the vascular system, all vessels into which the catheter is placed, and the route the catheter took to get to these vessels. Documenting variant anatomy encountered during the procedure also is necessary as this may affect coding.

The following concepts, along with good physician documentation, will allow you to code even the most challenging reports.

Know These Key Terms

To gain a better understanding of arterial system catheter placement coding, familiarize yourself with these key terms.

Vascular access is the location(s) where the patient’s vascular system is entered. The common femoral artery (CFA) and brachial arteries are the most frequently used.

A vascular family is a vessel that arises from the aorta or is off the access vessel, and includes all of that vessel’s branches. For example, the left subclavian artery and its many branches are considered as one vascular family off the aorta.

Non-selective catheter placement refers to a catheter that remains in the accessed vessel or that has made it into the aorta, which is still considered non-selective.

Selective catheter placement is a catheter placed into (not at or near the origin) a branch off the aorta or the access vessel. Each of these vessels arising from the aorta or access vessel represents different vascular families. Code to where the tip of the diagnostic or working catheter is placed, but not the wire. A working catheter could be an angioplasty, atherectomy, or stent catheter.

Vascular order describes the level of a vessel. The initial vessel off the aorta or access vessel is considered a first-order vessel. When this initial vessel starts to branch, it becomes smaller and more difficult to catheterize, with the resulting branches becoming second-order selections. When the second-order vessel starts to bifurcate, the resulting branches become third-order selections, and so on. The highest level of selection in the arterial system is a third-order vessel, so it is not necessary to distinguish higher levels of selection. One main exception is that the popliteal artery becomes the next-higher order beyond the SFA without a bifurcation.

Apply Coding Guidelines

Refer to Table A for code descriptions.

• Select the appropriate non-selective code when an access is made and the catheter does not reach the aorta or a branch off the access vessel. For example, if the right common femoral artery is entered and a sheath is placed for a right lower extremity angiogram, the catheter placement code is 36140.
• Do not report a separate code for the access site (sheath placement) when the aorta is entered or there was a selective catheter placement.
• Report 36200 when the catheter enters the aorta (which is non-selective). Remember not to code where the tip of the wire is placed, but rather where the sheath, diagnostic catheter, or working catheter tip is placed. For example, during an ostial stent placement in a renal artery, the wire may be placed into a second- or third-order vessel for stability, but the correct code is 36245 because the catheter the stent was deployed from is a first-order selection.
• Call upon the appropriate selective code when a vessel off the aorta or access vessel is entered. The documentation must confirm that a particular vessel was selected, or that the catheter tip was placed into the vessel. Placement of a catheter “near” or “at” the origin of a vessel does not document a selective catheter placement.
• The selective code includes the non-selective code from the same access site. For example, if the right renal is selected, report only 36245, not 36200 and 36140 from a transfemoral approach.
• Code once the highest order/level of catheter selection within a vascular family (e.g., 36xx5, 36xx6, or 36xx7). If, in the same vascular family, additional branch vessels are catheterized, use the appropriate additional second-order, third-order, and beyond code (36218 or 36248) for each additional vessel that is selected. These are add-on codes and do not require modifier 59 Distinct procedural service for multiple service units.
• The highest level vessel selected in a vascular family includes the lesser-order selective codes in route. For example, if the celiac, common hepatic, and right hepatic are separately injected, report only 36247 (the less selective procedures 36246 and 36245 are included).
• Repeat the same guidelines above for each separate vascular family that is selected. For example, in a normal aortic arch, if each of the great vessels (e.g., brachiocephalic, left common carotid, and left subclavian) are selected, you will have a minimum of three codes to report (36xx5, 36xx6 or 36xx7). If additional vessels within any of these three vascular families are also selected, additional (36xx8) code(s) are necessary.
• If a second access is performed, the coding starts again following the same guideline above for any and all vessels selected. For example, if the right femoral is entered and a catheter is placed into the bilateral renals and a second access is made into the left femoral with a catheter placed into the aorta, the reported codes would be 36245-50 and 36200-59. Modifier 59 indicates this to be a separate and distinct procedure, while modifier 50 Bilateral procedure describes the bilateral access to the renals.

Real Scenarios Reveal Correct Coding

Case 1 – Right transfemoral approach with the right vertebral, right common carotid artery, left common carotid artery, left vertebral arteries selected with normal arch anatomy.

Catheter codes: 36217, 36218, 36215-59, 36216-59

Case 2 – As case 1, but with bovine arch (variant anatomy with left common carotid originating from the brachiocephalic, resulting in only two vascular families arising from the arch instead of the normal three).

Catheter codes: 36217, 36218, 36218, 36216-59

Notice different codes secondary to the variant anatomy.

Case 3 – Right transbrachial approach with the same vessels selected as in case 1.

Catheter codes: 36215-59, 36215-59, 36215-59, 36216-59

Notice different codes for different approach.

Case 4 – Right transfemoral access with the celiac, splenic, gastroduodenal, and superior mesenteric arteries selected.

Catheter codes: 36247, 36248, 36245-59

Remember: The celiac would be included in the third-order selection in the same vascular family.

Case 5 – Left transfemoral with an up-and-over contralateral approach with the right SFA, popliteal, anterior tibial, posterior tibial, and peroneal arteries selected.

Catheter codes: 36247, 36248, 36248

These codes are for the anterior tibial (AT), posterior tibial (PT), and the peroneal arteries. The SFA and popliteal are “along the route” to the highest level selection and are not reported separately.

Table A

Non-Selective Arterial Codes

36100      Introduction of needle or intracatheter; carotid or vertebral artery

36120      Introduction of needle or intracatheter; retrograde brachial artery

36140      Introduction of needle or intracatheter; extremity artery

*36147     Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

*+36148   Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (List separately in addition to code for primary procedure)

36160      Introduction of needle or intracatheter, aorta, translumbar

36200      Introduction of catheter, aorta

Selective Arterial Codes Above the Diaphragm

36215      Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family

36216      Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family

36217      Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family

+36218    Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

Selective Arterial Codes Below the Diaphragm

36245      Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36246      Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36347      Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family

+36248    Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

* New code for 2010

Here’s the information you need to code anal surgery in 2010.

By G. John Verhovshek, MA, CPC

The anal surgery section (46020-46999) of CPT® 2010 contains nearly two dozen added, deleted, or altered codes from 2009. A quick review of these changes will keep your claims clean in the year ahead.

Read more »

From diabetes to multiple gestation complication, correct code sequencing is essential.

By Pamela K. Kostantenaco, LPN, CPC, CMC

In the world of high-risk pregnancies, it is important that you code the maternal or fetal conditions accordingly. Correct sequencing is especially important in cases where multiple codes are needed. Read more »

When medical necessity drives documentation, optimal coding will result.

By G. John Verhovshek, MA, CPC

Aggressive claims review by government and private payers has brought a much needed spotlight to the shortcomings of medical documentation in support of optimal coding and reimbursement. This is a positive development, but what’s important to remember is that coding never should drive documentation. The idea, for instance, that “if only the doctor had documented one more bullet …,” even if well-meant, is wrong-headed. Rather, documentation rooted in medical necessity that accurately reflects the service level provided always will drive coding to the optimal level. Read more »

EMR documentation can create risky record keeping.

By Cheryl L. Toth

Documentation like the following is becoming more common as coding consultants audit practices that have moved to an electronic medical record (EMR):

• A 90-year-old woman who “denied pregnancy as a sign.”
• An infant with “good dentation.”
• The note for every female patient in a general surgery practice indicating a “full pelvic exam performed.”

“The overarching issue here is lack of visit template customization,” says Mary LeGrand, RN, MA, CPC, CCS-P, consultant with Chicago-based KarenZupko & Associates. “A critical component of EMR planning is customizing your visit templates—in addition to tailoring other elements of the system,” says LeGrand. “In most cases, you get little to no template customization help from the vendor. It’s up to a busy physician to do in his or her ‘spare time.’ And many practices fail to realize the importance of this step.” Read more »

Knowing the challenges can help with implementation and orientation to a new system.

By Janice G. Jacobs, CPA, CPC, CCS

Electronic health records (EHRs) are electronic versions of a patient’s medical history as maintained by a physician or other health care provider. EHRs contain elements such as patient information, past medical, family and social history, clinical notes, prescriptions, and diagnostic testing results. These records are accessible to other health care providers and serve as a legal record of everything that happened to a patient during a specific encounter. EHR adoption is key to the current administration’s health strategy. If you are confused about what’s happening, here’s a primer.

Taking the Next Step in Health Care Data

The Centers for Medicare & Medicaid Services (CMS), Electronic Health Records, Overview (www.cms.hhs.gov/ehealthrecords/) says, “EHRs are the inevitable next step in the continued progress of health care that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.”

Examples of how EHRs can improve patient care include the following:

•  Reducing incidence of medical error by improving the accuracy and clarity of medical records.
• Making the health information available.
• Reducing duplication of tests.
• Decreasing treatment delays.

The government is uncovering and addressing implementation issues through a series of demonstration projects prior to the 2014 projected nationwide rollout. CMS is engaged in a five-year EHR demonstration project, which began on June 1, 2009 and is anticipated to continue through May 21, 2014 (found at CMS, Medicare Demonstrations, Details for Electronic Health Records Demonstration:www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1204776). 

The goal of the demonstration is “to foster the implementation and adoption of EHRs and health information technology (HIT) more broadly as effective vehicles to improve the quality of care provided and transform the way medicine is practiced and delivered … The demonstration is designed to leverage the combined forces of private and public payers to drive physician practices to widespread adoption and use of EHRs,” (CMS, Medicare Demonstrations, Details for Electronic Health Records Demonstration). The demonstration provides incentives to participating primary care physician practices fulfilling established criteria and serves as an operational outline for practices across the country in relation to infrastructure, physician education, tracking and reporting quality measures, and community outreach.

Increase Financial Benefits with Early Implementation

In February 2009, President Obama signed the American Reinvestment and Recovery Act (ARRA, or stimulus act), which included the Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH includes more than $19 billion used to increase EHR use nationwide. Under the stimulus plan, physicians can qualify for $44,000 in Medicare incentives if they demonstrate “meaningful use” of an EHR starting in 2011. High-volume Medicaid providers can be eligible for up to $20,000 more in incentives, for a maximum incentive of $64,000. Physicians in health professional shortage areas (HPSA) are eligible for an additional 10 percent incentive.

Specific criteria must be met before a provider is eligible for stimulus payments. The two most important criteria require that (1) the EHR must be a “qualified” EHR and (2) the provider must demonstrate “meaningful use.”

To be considered qualified, an EHR must:

• Include patient demographic and clinical health information.
• Have the capacity to provide clinical decision support.
• Support physician order entry.
• Capture and query information relevant to health care quality.
• Be able to exchange electronic health information and integrate information from other sources.               

The definition of meaningful use is muddy and will be clarified further by the Health IT Policy Committee. Meaningful use most likely will involve consistent use of the EHR for prescribing, electronic exchange of health information between clinical organizations, and the submission of information on selected quality measures. A provider who purchases an EHR system but fails to use it would be disqualified from stimulus eligibility. Stimulus funds are distributed per provider number rather than to individual physicians; meaning, if a group of five doctors operating under one provider number purchases a qualified EHR system and demonstrates meaningful use, the practice will be eligible for up to $44,000. Each physician will not receive his or her own stimulus payment and the practice, as a whole, must demonstrate meaningful use. One physician acting as the champion in regard to technology, who spearheads the EHR project but is the only meaningful user of the EHR system, would not qualify the entire practice for the incentive.

Stimulus payments will be staggered over a five-year implementation period: $15,000 (year one), $12,000 (year two), $8,000 (year three), $4,000 (year four), $2,000 (year five), and $0 for subsequent years. To be eligible for the full amount, the EHR system must be up and running by Jan. 1, 2011 to demonstrate meaningful use by 2012, when incentive payments will begin. Practices that have adopted a qualified EHR system prior to Jan. 1, 2011 also will be eligible for the incentive payments. Meaningful users who have systems up and running in 2011 and 2012 will receive an increased first year payment of $18,000. Practices implementing a qualified EHR after 2011 will be eligible only for that year’s payments. For example, if a practice is up and running in 2011/2012, they will get year one’s payment and payments each subsequent year for five years. A practice that implements an EHR in 2013 will start receiving the reduced year two payment and receive payments each subsequent year for four years.

Incur Financial Penalties with Late Adoption

The biggest obstacle in implementing EHRs in private and group practices is cost. With the financial incentive program, expense should be less of an issue for physician practices to adopt a functional EHR. In an ongoing effort for full compliance, further negative incentives will be implemented after the demonstration project is over. Beginning in 2015, penalties (reduced fee schedule payments) will be assessed for providers that are not meaningful users of a qualified EHR system. The penalty will increase each subsequent year of noncompliance, to as much as 5 percent by 2018.

Weigh the Impact on Patient Care and Finances

As a result, every practice should assess its specific needs for a qualified EHR system. It is imperative to work with the business office or central business office in cases of large group practices with many locations. The new EHR system will not provide return on investment if it does not interface with the existing billing and accounts receivable system. Practice managers and clinicians need to consult with the billing and accounts receivable (BAR) office about evaluating vendors to achieve optimal interoperability between systems and offices. Failure to include the front and back ends of the revenue cycle will result in significant cash flow problems during implementation.

Your physicians also will need sufficient preparation to become acclimated to a new system, so there will be limited impact on the number of patients seen in a day with no adverse effects on patient care quality. Careful planning is necessary to implement the EHR system gradually, starting with the clinical data first, and then moving to implementation of the billing system where encounter form data is entered. If care quality and billable hours are affected substantially because a physician is spending excessive time in front of a computer keying in data, there will be a negative return on investment.

Computerizing the nation’s health records as part of the economic stimulus plan has resulted in mixed emotions. Although providers agree that quality of patient care quality will increase with EHRs, they are faced with the challenges of implementation and orientation to a new system. With the topic of EHRs on the CMS agenda since the early 90s, it’s still a top priority as CMS moves forward with the EHR demonstration project as part of their value-driven health care initiative. As the President designates funds and resources to fulfill the goal of Americans having access to a secure, interoperable health record by 2014,analyzing your practice’s current capacity and resources for implementing EHR is critical to your five-year strategic plan.

Straighten any kinks in initial subluxation claims with good documentation.

By Marty Kotlar, DC, CHCC, CBCS

Question: I have been treating Medicare patients for the last three years and my office manager recently told me there are specific chiropractic guidelines for a Medicare patient on the initial visit. I did not know that. I just perform my normal history and examination, take X-rays, and do not follow any special system. Should I be doing something different?

Answer: Your office manager is correct: There are specific guidelines Medicare wants doctors of chiropractic to follow. Whether you are meeting those guidelines is hard to tell for sure without knowing what you are documenting presently when you perform your history, exam, and X-ray findings.

A chiropractor is defined in the Social Security Act (section 30.1.) as a physician only for manual manipulation or treatment of subluxation of the spine. The following eight items must be documented in the Medicare patient’s clinical record on the initial visit, whether the required subluxation is demonstrated either by X-ray or physical examination:

1. History – A chief complaint must be documented, including the symptoms present causing the patient to seek chiropractic treatment.

2. Present Illness – This can include any of the following, as appropriate:

• Mechanism of trauma
• Quality and character of problem/symptoms
• Intensity of symptoms
• Frequency of symptoms occurring
• Location and radiation of symptoms
• Onset of symptoms
• Duration of symptom
• Aggravating or relieving factors of symptoms
• Prior interventions, treatments, including medications
• Secondary complaints
• Symptoms causing patient to seek treatment

3. Family History

4. Past Health History – This should include:

• General health statement
• Prior illness(es)
• Surgical history
• Prior injuries or traumas, past hospitalizations (as appropriate)
• Medications

5. Physical Examination – Evaluation of musculoskeletal/nervous system through physical examination to identify:

• P = Pain/tenderness evaluated in terms of location, quality, and intensity;
• A = Asymmetry/misalignment identified on a sectional or segmental level;
• R = Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
• T = Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned are required, one of which must be asymmetry/misalignment or range of motion abnormality.

Note that a patient’s subluxation/condition is considered chronic when it is not expected to resolve completely, as is the case with an acute condition, but where the continued therapy is expected to result in some functional improvement. If an extensive, prolonged course of treatment is necessary, clearly document it in the clinical record. Coverage will be denied if it is not reasonably expected that continued treatment will result in improvement of the patient’s condition. Continued repetitive treatment without a clearly defined clinical end point is considered maintenance therapy and is not covered.

Complete requirements for chiropractic services under Medicare may be found in the Medicare Benefit Policy Manual, chapter 15, section 240, “Chiropractic Services,” which may be found on the Centers for Medicaid & Medicare Services (CMS) Web site: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Be sure to read your local Medicare carrier’s guidelines for chiropractic services.

6. Diagnosis – Most Medicare carriers require the primary diagnosis to be subluxation with the neuromusculoskeletal condition causing the treatment to be listed as the secondary diagnosis.

7. Treatment Plan – This should include:

• Therapeutic modalities to effect cure or relief (patient education and exercise training)
• The recommended care level (the duration and frequency of visits)
• Specific goals to be achieved with treatment
• Objective measures that will be used to evaluate the effectiveness of treatment
• Date of initial treatment

8. Signature/initials – This is required to authenticate the records.

For additional information, see also the American Chiropractic Association (ACA) Web site: www.acatoday.org/pdf/part_process.pdf.

Don’t settle for a portion of payment—get the full amount.

By Meera Mohanakrishnan, CPC, CPC-H

Frequently, the total service/procedure described by a single CPT® code is comprised of two distinct portions: a professional component and a technical component.

The professional component of a diagnostic service/procedure is provided by the physician, and may include supervision, interpretation, and a written report. The extent and nature of the professional component depends on the precise service/procedure rendered. For example, a written report generally is required, but may not be necessary for a supervising pathologist to claim professional services in a clinical laboratory (see “Professional Services in the Clinical Lab: Billable or Not?” Coding Edge, July 2009, pages 48-49). When required, the interpretation of a diagnostic test should be a separate report, signed by the physician.

The technical component of a diagnostic service/procedure accounts for equipment, supplies, and clinical staff (such as technicians). Payment for the technical component also includes the practice and malpractice expenses. Fees for the technical component generally are reimbursed to the facility or practice that provides or pays for equipment, supplies, and/or clinical staff.

Procedures/services that may include both a professional and technical component are found commonly within the Radiology, Pathology and Laboratory, and Medicine chapters of CPT®. The surest way to identify codes with separate professional and technical components for Medicare payers is to consult the National Physician Fee Schedule Relative Value File, available for download on the Centers for Medicare & Medicaid Services (CMS) Web site. (The most recent file as of January 2010 may be found at: www.cms.hhs.gov/PhysicianFeeSched/pfsrvf/list.asp?listpage=4.) If the Relative Value File lists separate line items for a code with modifiers 26 Professional component and TC Technical component, the service/procedure described by that code includes both a technical and professional component.

For example, the 2010 Relative Value File lists three separate lines for 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material. The first of these lines corresponds to the “global” service, which is assigned 6.10 relative value units (RVUs) (all RVUs cited are fully implemented facility and non-facility totals). The second line details the technical component only, with 4.37 total RVUs. The third line describes the professional component of 70480, at 1.73 RVUs. Note that the RVUs for the technical and professional components will equal the total RVUs for the global service (4.37 + 1.73 = 6.10).

Professional Services Call for Modifier 26

Separate payment can be made for the technical and professional components of a procedure when each is performed by different professional providers. For instance, the technical component of a service/procedure may be performed by the clinic, but the professional component is performed by an outside physician or laboratory. In such situations, providers must submit their claim and bill only for the service performed.

To identify professional services only for a service/procedure that includes both professional and technical components, append modifier 26 to the appropriate CPT® code, as instructed in CPT® Appendix A, “Modifiers.” Note that modifier 26 is appropriate when the physician supervises and/or interprets a diagnostic test, even if he or she does not perform the test personally.

When only the professional component of a service is provided, failure to report modifier 26 will cause the claims to adjudicate incorrectly and lead to recovery as permitted by law. Modifier 26 should not be used, however, if there is a specific code that already describes only the professional/physician component of a given service. For example, it is inappropriate to append modifier 26 to 93722 Plethysmography, total body; interpretation and report only because the code does not include a technical component, but describes professional services solely.

Modifier TC Identifies Technical Component Only

Appending modifier TC indicates that only the technical component of a service/procedure has been provided. Generally, the technical component of a service/procedure is billed by the entity that provides the testing equipment.

Note that physicians providing services for Medicare patients in a hospital or facility setting cannot claim the technical portion of a procedure regardless of whether the physician owns the testing equipment. Under the diagnosis-related group (DRG), the hospital/facility receives payment for the technical component of Medicare inpatient services. Similarly, Medicare rules require payment for non-physician services provided to hospital patients (such as the services of a technician administering a diagnostic test) to be made to the hospital.

Just as there are codes describing professional-only services for Medicare, so are there codes describing technical component-only services. Do not apply modifier TC (or 26) with such codes. For example, 93005 Electrocardiogram; tracing only, without interpretation and report is covered only as a diagnostic tests and does not have a related professional code. The total RVUs for technical component-only codes include values for practice and malpractice expenses only.

Global Billing Doesn’t Require 26/TC

As explained previously, the global service includes both the professional and technical components of a single service. When reporting a global service, no modifiers are necessary to gain payment for both components of the service. Never report a single procedure code with both modifiers 26 and TC.

For example: Code 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete describes a service that includes both a technical component (the ultrasound machine, along with necessary supplies and clinical staff to support its use) and a professional component (physician supervision, interpretation, and report).

If pelvic ultrasound is performed at the physician’s office, either by a physician or a technician employed by the practice, the physician reports 76856 without a modifier because the practice provided both components of the service.

On other hand, if the physician performs the same procedure at the hospital, the physician would report 76856-26 for the professional component only. The hospital would claim separate reimbursement for the technical component (76856–TC) because it owns the ultrasound equipment.

Note that in all reported cases, modifiers 26 and TC are considered payment modifiers and must be reported in the first modifier field.

When time captures reimbursement, every minute counts.

By G. John Verhovshek, MA, CPC

As CPT® evaluation and management (E/M) service guidelines explain, “When counseling and/or coordination of care dominates … the physician/patient and/or family encounter … time may be considered the key or controlling factor to qualify for a particular level of E/M services.” Specifically, in the office setting, time-based E/M coding requires that the physician spend half or more of the visit face-to-face with the patient and/or family providing counseling and/or coordination of care.

In a hospital or nursing facility, the counseling/coordination of care time needn’t be face-to-face, but may include floor/unit time within a 24-hour period. CPT® E/M guidelines allow unit/floor time to include “the time that the physician is present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient’s medical chart, examines the patient, writes notes and communicates with other professionals and the patient’s family.”

Time Reference are Crucial

Only those E/M services with a time reference may be reported using time as the key component. The time reference is stated in the final sentence of the CPT® E/M code descriptor. For instance, consider the descriptor for new patient outpatient service 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Note that it specifies, “Physicians typically spend 30 minutes face-to-face with the patient and/or family.” In contrast, according to CPT® guidelines, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity bases.” Likewise, observation codes 99234-99236 do not have a time reference. Because these services do not include time references, you should not report them with time as the controlling element.

With regard to time references, CPT® explains that “specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.” In other words, not every level III, new patient, outpatient service (99203, as described above) will last 30 minutes. Conservative coding suggests the stated time reference is the minimum necessary to report a service by time. For instance, to report 99203, the visit would be at least 30 minutes, with at least 16 (50 percent or more) spent on face-to-face counseling and coordination of care. To report a level IV, new patient, office visit (99204) by time, the visit would need to last at least as long as the stated time reference of 45 minutes, and so on, as shown in Table A.

Note that time spent taking the patient’s history or performing an examination does not count as counseling time.

Count the Minutes, Note the Substance

Documentation is crucial when reporting time-based E/M services. As CPT® explains, “The extent of counseling and/or coordination of care must be documented in the medical record.” Actual start and stop times for the service, if ideal, are not necessary. What is required, however, is the physician’s note for how long the session lasted (e.g., “28 minutes”), as well as what portion of that time was devoted to counseling and/or coordination of care.

Just as importantly, documentation should describe the substance of the counseling and/or coordination of care, advises Marcia Brauchler, MPH, CPC, CPHQ, with Physicians’ Ally, Inc. in Littleton, Colo. For example, CPT® instructions allow counseling to include discussion of one or more of the following:

• Diagnostic results
• Prognosis
• Risks and benefits of treatment options
• Impressions
• Instructions for management
• Importance of compliance with chosen treatment options
• Risk factor reductions
• Patient and family education

A common example is a patient with a new diagnosis of diabetes. The physician may spend extensive time with the patient discussing lifestyle modifications, including proper diet and exercise, as well as the nature of the disease, the importance of control, and so forth. The substance of the discussion should be included in the physician note to support an E/M service coded by time.

Use It, Don’t Abuse It

Coding E/M services by time is simpler than reporting services according to history, exam, and medical decision making (MDM), but don’t be tempted to report all E/M services by time. Keep in mind: the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services’ (CMS) guidelines consider history, exam, and MDM to be the key components of E/M services, and allow coding by time only when 50 percent or more of the visit involves documented counseling and/or coordination of care. The physician should include the components of history, exam, and MDM—even if cursory—in the documentation of every visit. Good medical record keeping requires documenting relevant and pertinent information. Using time as the controlling factor to qualify for a given E/M level does not negate this requirement.

Time-based E/M and Prolonged Services

Prolonged services codes (+99354-+99357) may be combined with other E/M services to report extended, face-to-face patient/provider visits. To report prolonged services, the physician must document at least an additional 30 minutes of face-to-face beyond the time reference of the chosen E/M service level, as illustrated in Table A. Do not report prolonged service codes in addition to any E/M services (such as observation services) that do not include a time reference.

Heads up: Codes +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) and +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) report non face-to-face prolonged services, but these are not recognized by Medicare and many other payers.

Time counted toward prolonged services need not be continuous, but it must occur on the same service date. Do not consider time spent discussing the patient’s case with other physicians, time reviewing data or tests without the patient present, or other activities not involving direct patient contact toward prolonged services.

Documentation must explain why the physician provided prolonged services. For example, CMS Internet Only Manual instructions state, “to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed.” A notation that the physician spent an extra 40 minutes with the patient, for instance, is not adequate. The medical record must support specifically medical necessity for the extra time spent.

Combining prolonged services with time-based E/M services raises interesting issues, Brauchler notes. “Looking at Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.15.1, you don’t have to max out the highest E/M level to add prolonged service time. This doesn’t necessarily make sense if you’re using time-based coding because, for instance, a 75 minute 99213 ought to be (by definition) a 99215, not a 99213 with 99354.”

Here’s the answer: Generally E/M levels are assigned according to history, examination, and MDM. If the physician spends 30 minutes or more beyond the time reference of the chosen E/M level on counseling and coordination of care, you’d apply prolonged services codes. If the physician spends fewer than 30 additional minutes beyond the reference time of the appropriate E/M level (as determined by history, exam, and MDM) with the patient—and counseling and coordination of care exceed 50 percent of the time allotted to the visit—you may choose to code a higher E/M level based on time.

For example, the physician sees an established patient with a newly-confirmed diagnosis of cancer. Based on the components of history, examination, and MDM, the visit warrants only a level III visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.). The physician spends an additional 40 minutes (beyond the 15-minute time reference of 99213) answering questions and discussing treatment with the patient. In such a case, you could report the office visit (99213) and one hour of prolonged services (99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)).

If the same patient presents for the same visit but lasting 20 additional minutes beyond 99213’s 25-minute time reference, don’t report prolonged services (because the 30-minute threshold for 99354 was not met). But, as long as the physician spends more than half the visit on counseling and coordination of care, you may use time as the key component when assigning the E/M level (which, in the case of this 45-minute visit, would result in a level V service, 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family).