Posts Tagged ER
By Stephen C. Spain, MD, FAAFP, CPC
Angela “Annie” Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT
Editor’s note: Health care reform brings a number of new concepts to coding, billing, compliance, and practice management. The most far reaching—especially from an organizational point of view—are accountable care organizations (ACOs). Below is the first of three articles detailing why ACOs exist, how they work, and what affect they will have on us.
“Quality” and “value” have percolated to the top of health care payers’ concerns in recent years. Payer initiatives currently in development will have a substantial, pervasive, and dramatic impacts on virtually all AAPC members—and on patients and providers, as well. These initiatives focus on reducing unnecessary medical services to lower costs, and on identifying effective practice patterns.
The Challenge Ahead
The United States has the planet’s highest per capita health care expenditures. In 2010, we spent $2.6 trillion on health care (an amount equal to the entire economy of France). By 2019, an estimated 19 cents of every dollar will be spent on health care. Even as health care costs rise rapidly, significant federal regulations require additional expenditure and investment in health care infrastructure and technology (e.g., 5010, ICD-10-CM, administrative simplification, health care reform, health information exchanges (HIEs), etc). Many industry stakeholders and lawmakers are looking to payers and providers for ways to reduce costs, while ensuring efficacy and quality.
Nearly 32 million Americans do not have health insurance, which places an additional burden on health care reimbursement (the number of uninsured may change due to provisions in the Patient Protection and Affordable Care Act (ACA)). Patients without health insurance often do not seek care until they are very sick, which requires higher levels of care and higher utilization (e.g., emergency room (ER) visits, high-end radiological studies, etc.). For many uninsured, the ER—perhaps the most expensive setting in which to receive care—is the sole means of care. This requires states and hospitals to create uncompensated care pools for economically qualifying individuals. Uncompensated care pools lift health care costs through write-offs, increases in delivery costs, and higher premium rates.
For Payers, Quality Requires Value
As patients, when we consider the quality of our health care, we may think about how well trained our providers are, or how well equipped our local hospital is. But for those paying for health care on our behalf (employer-engaged insurance companies and the Centers for Medicare & Medicaid Services (CMS)), quality is defined as value received for the dollars spent. Payers don’t want to waste money on care that is medically unnecessary, care that is billed but not rendered, or treatments that are not proven.
In response, many payers have taken steps to implement quality-monitoring measures outside of the traditional-managed care model. For example, payers may create wellness programs and disease management programs to promote effective treatment methods and drive higher quality of care. Typically, payers will target high cost (often chronic) conditions such as diabetes, asthma, kidney disease, and heart failure, and create resources and tools to ensure that patients/members understand what quality care is and that participating providers are rendering the best care available. We know from quality measures that disease management is helping performance outcomes around many chronic conditions; however, health care costs continue to rise. Although helpful from a quality perspective, disease management is not enough to curb rising costs.
A New Response to Better Care and Contained Costs
Many payers (including CMS) are looking to evidence-based medicine (EBM), a widely applied principle of identifying treatments and practice habits that are proven to be beneficial, and are encouraging all practitioners to adopt these treatments and practice habits as a universal “gold standard” or “best practices.”
Before EBM, as new advances were made in medicine, it was assumed that the information would trickle down in meetings, seminars, and publications and that eventually all practitioners would become aware of the advances and adopt them. In reality, this model did not work. Providers trained one way generally stuck to what they knew, and were not eager to adopt new ways of practicing medicine.
In the 1990’s, the U.S. Preventive Health Services Task Force (USPSTF) was organized to review available medical data and make recommendations on which preventive services (Pap screening schedules, mammography screening, colonoscopies, etc.) should be applied to the entire population. Several medical groups, such as the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP), decided to build on the work of the task force and identify meaningful diagnostic and medical treatments for a variety of conditions. Where double-blinded, controlled studies support a recommendation, it would have the highest rating. Where medical study or evidence supporting a treatment or service is lacking, the item would have the lowest recommendation (or would not be recommended at all).
For example, at one time patients complaining of low energy were commonly given 1,000 units of B-12 as an injection. Studies eventually showed that there was no appreciable benefit to B-12 injections; therefore, B-12 injections for a “boost” are not recommended. (CMS stopped paying for B-12 injections with a fatigue diagnosis many years ago.)
Finding the Middle Ground
Patient expectations can lead to difficulties in implementing EBM recommendations. For example: Studies have shown that X-rays for an acute ankle sprain, in the absence of other risk factors, are not necessary. Several medical groups are on record as advising against X-rays in the initial evaluation of an acute ankle sprain. Following EBM guidelines, providers would not routinely order X-rays for the average patient with an acute ankle sprain.
But what happens when you go to the ER with an ankle sprain? Almost always, your ankle will be X-rayed (and almost always, the X-ray will be normal). The patient wants reassurance, and the ER doctor does not want to risk being sued on the remote chance that he might miss a fracture. Patient pressure and medical liability worries result in an unnecessary X-ray. Hundreds of thousands of such unnecessary treatments are rendered every year.
EBM will likely ensure medical care improves in both quality and value. But based on our example, EBM might not provide the care the patient wants or the physician is comfortable providing. The goal is to find the point of equilibrium, where our health care delivery system offers quality and value, as well as improved outcomes. It will take time, patient and provider education, and control of liability exposure to incorporate EBM into everyday medical care.
How Quality Measures Enhance Value
Payers (CMS in particular) have turned to the reporting of “quality measures,” most of which are based on a framework provided by EBM, to improve the value received for health care expenditures. Just after the turn of this century, CMS created the Premier Hospital Quality Improvement Project. It offered incentive payments to health professionals for reporting quality measures. You may have heard of this as “pay for performance” or “P4P.” The idea was to test the hypothesis that providers would report quality measures if they were paid extra to do so. It was a very successful experiment and proved that paying extra could produce the information CMS was seeking. From this experiment, the Physician Quality Reporting Initiative (PQRI) was born. PQRI has since become a permanent program, renamed the Physician Quality Reporting System (PQRS).
PQRS relies on “measures” tabulated over the course of a patient’s treatment. CMS realized it needed help from the medical community to determine what measures were important. EBM was used, wherever possible, as the guiding principle. The actual quality measures were developed by various medical organizations, such as the AMA, the American Gastroenterology Association (AGA), and others. These groups have put together several hundred measures that cover issues pertinent to most medical specialties and health care providers.
As an example of how a quality measure enhances value, consider the pneumonia vaccine. There is a quality measure for reporting that a patient is current on a pneumococcal pneumonia vaccine. If the patient is noted to be current at a visit, a code is added to the patient’s claim. If a provider finds that a patient is not current on his or her vaccine, he would administer the vaccine and report the code for that service, as well as a quality measure code for providing the vaccination. In this way, fewer patients will slip through the cracks and fewer Medicare patients will succumb to pneumococcal pneumonia. The value comes from the saved expenses of pneumonia treatment and hospitalization.
Quality Measure Reporting Requirements
Early indications are encouraging that reporting of quality measures will make providers less likely to overlook vaccinations (pneumonia, flu, tetanus, hepatitis B), preventive screenings (colonoscopy, Pap smear, mammography, PSA screening), counseling on health issues (smoking, obesity, fall risk), and treatments known to be effective for certain health conditions (statins for diabetes and heart disease, ACE inhibitors for congestive heart failure, aspirin for early myocardial infarction, anticoagulants for atrial fibrillation). A provider can pick several pertinent measures and report those for a year for the applicable patient encounters. The measures can be reported by either attaching a HCPCS Level II code to the claim for the encounter, submitting the information to a third-party registry, or through an electronic health record with PQRS reporting capability built in.
As an example, an endocrinologist may decide to report measures for diabetes. There are a number to choose from, but here are three that could be used:
- DM: Hgb A1C with poor control A1C >9.0%
- DM: LDL cholesterol controlled LDL-C < 100 mg/dl
- DM: High BP controlled BP < 140/90
Three measures are selected because three is the minimum number of quality measures a provider can report to be eligible for a bonus payment. To successfully report these parameters, the provider must address and report these items once in the course of the year—ideally, for every patient seen with a diabetes diagnosis. To qualify for an incentive payment, the measures must be reported for at least 80 percent of the eligible encounters.
There is no way to track progress with CMS over the course of the year, and many providers only learn after the year has ended if they met the criteria for a bonus payment. Currently, the bonus is 0.5 percent of the total Medicare payments received by the provider for the year. Unless there are changes, the bonus is phased out after 2014. Starting in 2015, penalties will apply for providers who do not report or who improperly report quality measures. The penalty in 2015 is 1.5 percent, which will increase to 2 percent in 2016, and will be applied against ALL Medicare payments.
CMS is not doing much with the quality measures data it is collecting, but that will change. Right now, most of the measures seem to be aimed at making sure that important treatment guidelines are not overlooked (e.g., blood pressure goals and aspirin for heart attack victims, and certain drugs for heart failure and diabetes care).
Measures’ reporting is almost certainly here to stay. Note that PQRS preceded and is separate from the ACA law, so PQRS is not likely to be affected by changes in the ACA interpretation or implementation.
Next month, we will feature part two of this three-part series: The (R)evolution of the ACO.
Dr. Spain, MD, FAAFP, CPC, has worked in family medicine for over 25 years. In 1998, he founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at firstname.lastname@example.org.
Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, is the director of 5010/ICD-10 communication, adoption, and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College, and a developer and member of AAPC’s ICD-10 training team. Ms. Boynton frequently speaks and writes about coding, including ICD-10 and 5010 implementation.
November 1st, 2012
Place of service errors are on the OIG hit list, so be sure your coding is up to par.
By G.J. Verhovshek, MA, CPC
For the third consecutive year, the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) has included place-of-service (POS) errors as an area for review in its annual Work Plan. Judging from the results of several OIG audits over the past decade, POS coding is indeed a serious problem for many practices and facilities. Now’s the time to review your own POS coding to ensure you don’t become a target for OIG investigation, repayment demands, or worse.
How POS Affects Payment
POS codes are two-digit codes used to indicate the setting in which a health care service was provided. There are approximately 50 POS codes; among the most familiar are 11 Office, 21 Inpatient hospital, and 24 Ambulatory surgical center (ASC). A complete list of POS codes may be found in the Medicare Claims Processing Manual, chapter 26, section 10.5. The American Medical Association’s (AMA’s) CPT® Professional Edition also includes a list of POS codes on the page adjacent to the inside front cover.
The coded POS has a direct impact on payment for services provided. As explained in MLN Matters® number: SE1104, “To account for the increased practice expense that physicians generally incur by performing services in their offices and other non-facility locations, Medicare reimburses physicians at a higher rate for certain services performed in these locations rather than in a hospital outpatient department or an ASC.”
A correct POS code ensures that Medicare does not incorrectly reimburse the physician for the overhead portion of a service performed in a facility setting. On the flip side, an incorrect POS code may result in overpayment if a physician provides a service in a facility setting, but indicates the service was provided in a non-facility setting.
Frequent Errors Raise OIG’s Ire
Assigning a POS seems initially straightforward—just determine where the service occurred and key in the correct code. As it turns out, however, POS errors are astonishingly frequent. And at a time when every health care dollar is being squeezed and scrutinized, POS errors have become a very big deal for government payers and auditors.
As an example of how pervasive POS errors are, the OIG audited select claims for a single payer (TrailBlazer Health Enterprises, LLC) for the two-year period Jan. 1, 2001-Dec. 31, 2002. Of those claims audited, 67 percent contained POS errors. From this, the OIG estimated TrailBlazer overpaid physicians $1,051,477 over the 24 months. In another audit involving claims submitted to National Heritage Insurance Company (NHIC) during 2002-2003, 81 percent of sampled claims contained POS errors. The OIG estimated that for all claims during the sample period, NHIC had overpaid physicians a total of $4,254,613 due to inappropriate POS codes.
In the results of a third audit published in 2010, the OIG estimated that Medicare contractors nationwide overpaid physicians $13.8 million during 2007 due to POS errors. An incredible 90 percent of claims sampled during the audit contained POS errors, in which physicians used non-facility POS codes on their claims for services that were actually performed in hospital outpatient departments or ASCs.
Partly as a result of these audits, the OIG has included POS errors as an area of investigation in its annual Work Plan since 2010. The 2012 Work Plan specifies, “We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service.”
The message from the OIG is clear: A crackdown of POS errors is underway.
Avoid POS Problems
The OIG identified several factors as the most common causes of POS errors:
- Default physician billing software settings
- Physicians’ billing personnel or agents were confused about the precise definition of a “physician’s office,” or were following established practice in applying the office POS code
- Physicians’ billing agents were unaware that an incorrect POS code could change the Medicare payment for a specific service
- Personnel made isolated data entry errors
In other words, most errors are mistakes rather than intentional efforts to gain overpayments—but that won’t prevent payers from seeking repayments if they find POS errors (in fact, seeking repayments is exactly what the OIG has suggested payers do). The good news is: The best way to prevent POS errors may be simple awareness of the problem.
All coding and billing personnel must know that POS codes affect reimbursement. POS codes should be double-checked prior to claims submission, and POS coding should be part of your internal auditing process. If possible, change billing software so the POS does not default to “physician office,” but rather requires that billing personnel enter the POS. If you use a third-party billing company, alert them that POS errors are on the radar for payers and the OIG.
Above all, providers should verify that they are reporting the POS code that applies to the setting in which the service was provided, and that the submitted procedure code is compatible with that POS. For example, Office or Other Outpatient codes (procedure codes 99201-99215) should be billed with POS codes 11, POS 22 Outpatient hospital, etc., whereas home service (99341-99350) should be billed with POS 12 Home.
Clear Guidance on POS Definitions
Occasionally, a POS error occurs because of genuine confusion over exactly how the POS is defined. For example, what is the POS if a physician leases office space from an ambulatory surgery center (ASC)? If a physician sells his or her practice to a hospital, is the office location still considered freestanding for reimbursement purposes?
To clarify POS definitions, observe the following guidelines:
- An office (POS 11) is a location where the physician (or group) pays all of the overhead expenses, including rent (or mortgage), staff salaries, supplies, utilities, etc.
- In an outpatient hospital (POS 22), the hospital employs the staff, owns the space, and incurs all of the overhead expenses. The hospital bills a facility fee to cover the cost of the expenses. Outpatient hospital locations include the observation unit, outpatient surgery unit, endoscopy suite, and hospital clinics.
- An emergency room (POS 23) is a hospital location where emergency diagnosis and treatment of illness or injury is performed. The hospital charges a facility fee to cover the overhead costs.
- An inpatient hospital (POS 21) includes all services provided to a patient that has been formally admitted to the hospital. All overhead expenses are billed through the hospital.
- An ASC (POS 24) is certified by Medicare to perform designated surgical procedures. The ASC bills a facility fee to cover the cost of overhead associated with the procedures. Laboratory and radiology services, other than those performed to assist in a procedure, are not permitted in the ASC during the ASC hours of operation. Other non-surgical services, imaging, infusions, or diagnostic procedures not on Medicare’s list of ASC-approved services should not be performed in the facility.
POS = Location Where Patients Receive Service
Per the Centers for Medicare & Medicaid Services (CMS) Transmittal 2407, the place of service (POS) code for all physicians paid under the Medicare Physician Fee Schedule (MFPS) must match the setting in which the beneficiary receives the face-to-face service. Billable, non face-to-face services (such as when a physician interprets diagnostic test results) are billed to the POS in which the beneficiary received the technical portion of the service.
As an example, MLN Matters® number: MM7631 offers the following scenario:
“A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC [technical] portion of the MRI. The physician furnishes the PC [professional] portion of the beneficiary’s MRI from his/her office location. POS code 22 [outpatient hospital] will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.”
There are two exceptions to the rule that says the physician always uses the POS code where the beneficiary is receiving care as a hospital inpatient or an outpatient of a hospital, regardless of where the beneficiary encounters the face-to-face service.
1. When a physician, practitioner, or supplier provides services to a patient who is an inpatient of a hospital, the inpatient hospital POS code 21 will be used irrespective of the setting where the patient actually receives the face-to-face encounter.
2. Physicians or practitioners who perform services in a hospital outpatient department will use POS code 22 (outpatient hospital) unless the physician maintains separate office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42. C.F.R. 413.65. Physicians will use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42.C.F.R. 413.6. Use of POS code 11 (office) in the hospital outpatient department or on hospital campus is subject to the physician self-referral provisions set forth in 42 C.F.R 411.353 through 411.357.
References: Transmittal R2407CP and MLN Matters® Number: MM7631.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
May 1st, 2012
Capture conditions with clear, concise documentation to increase reimbursement and decrease risks.
By Karen Stanley, MBA, RN
A clinical documentation improvement (CDI) program is a great way to ensure your facility is capturing all relevant details of a patient/provider encounter. This, in turn, boosts clinical and financial outcomes.
CDI programs began in the 1990s. Most were pilot projects to assess how such programs affect physician documentation. They have become more common since 2007, when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare severity-diagnosis related groups (MS-DRGs). Accurate DRG reporting increases Medicare reimbursement and reduces compliance risks. CDI programs optimize DRGs by capturing conditions through clear, concise documentation.
Use Queries to Prompt Complete Documentation
Queries are an essential component of any CDI program. A query is a communication and education tool that prompts physicians to provide greater detail about under-reported conditions found in the medical record. For instance, if pneumonia is the primary diagnosis but the type is not noted, the query provides options to describe the condition as “viral,” “bacterial,” “community acquired,” or “hospital acquired.”
Clarification for specificity of a diagnosis-patient admitted with productive cough, yellow sputum x 3 days-CXR reveals right lower lobe infiltrates/Dx: Pneumonia:Zosyn 3.375 g IV qd ordered/sputum cx sent;
Can the origin/etiology of the patient’s pneumonia be further specified? Please type or dictate your response.
The resulting documentation better reflects co-morbidity/complication (CC) and major co-morbidity/complication (MCC) rates, which determine the case mix index. By contrast, nonspecific documentation leads to nonspecific coding. The true severity of illness, mortality rate, and intensity of service are not captured and patient care, data integrity, compliance, and reimbursement all suffer.
Queries can address several areas, for example:
- to specify the severity of a condition;
- to clarify the underlying cause of a presented symptom;
- to substantiate present-on-admission issue; or,
- to identify a potentially preventable complication.
The physician may answer the query verbally, in writing in the history or physical, in a progress note, or in the query form. Queries may be completed either concurrently (at the time of the physician/patient encounter) or retrospectively.
Ensure queries are clear, concise, and timely by developing clinical indicators to determine when the clinical picture suggests a particular diagnosis. These clinical guidelines should be written in the query template for each condition and updated appropriately. Several organizations offer example templates, or facilities can create their own guidelines based on medical literature (e.g., The New England Journal of Medicine).
Electronic vs. Paper Queries
Automated queries as part of an electronic health record (EHR) provide effective recording, tracking, and charting data from the medical record, and are gaining popularity. There are drawbacks to automated systems, however. If the query is in the queue with several other documents for the physician’s signature, the physician may sign the document electronically without answering the query.
Paper queries can be effective if automation is not an option. For example, at Civista Medical Center in Maryland, a clinical documentation specialist (CDS) attaches a color-coded query form the patient’s medical record. The physician reviews the record, assesses the patient, and answers the query. The CDS records the information in the CDI database, and the query form becomes a permanent part of the medical record.
Build Physician Support
In addition to well-executed queries, a successful CDI program requires the support of administration, ancillary staff members (such as case management), and—most of all—physicians. Physician resistance is high for two key reasons:
1. Time: Physicians’ primary focus is patient care, and anything that detracts from that immediate goal may be perceived as a distraction.
2. Education: To achieve accurate and concise documentation, physicians must be educated as to why it is important.
A clear, concise CDI plan must include physicians every step of the way. Here’s where your CDS and physician advisor come in.
The CDS’ role is to support and enhance physicians’ documentation efforts. The CDS is involved in every facet of the CDI program. The CDS formulates query templates, leads the team that delivers (electronic or paper) queries to physicians, records responses, and follows up on unanswered queries. The CDS formulates a working DRG and a target DRG, and evaluates the medical record for secondary diagnosis to increase the severity of illness. Coders review the DRG and secondary diagnosis. If this information helps to optimize the DRG, it is added to the final DRG for reimbursement. The CDS should provide feedback to various facility departments on the CDI program’s impact on quality, integrity, and reimbursement.
A CDS must have clinical knowledge (including anatomy and physiology), a mastery of ICD-9-CM coding guidelines, expertise in health care regulatory compliance, and strong verbal and written communication skills. Having a doctorate, master’s, or bachelor’s degree in a related health care discipline is essential.
The physician advisor is a liaison between the CDS, coders, and the medical staff. He or she is responsible for educating physicians on coding guidelines and new clinical terminology, and for optimizing physicians’ documentation of condition severity, acuity, risk of mortality, and intensity of service. The advisor may present information at the monthly staff meetings, assist in the development of queries, address admission denials and DRG modifications, work with health information management (HIM)/CDS personnel, and when necessary, approach physicians with unanswered queries. Together, the physician advisor and CDS should initiate a program to educate physicians about ICD-9-CM (and the forthcoming ICD-10).
The physician advisor is nominated or appointed by his or her physician peers (Physicians generally respond more favorably to a colleague than to administrators or support staff.). The qualified advisor can accurately analyze the health record, understands the complexity of the coding/prospective payment system, and provide in-services on medical conditions.
The Coder’s Role
Your role in the CDI program is paramount to its success. You will be using the query templates retrospectively if the physician does not answer the query concurrently. The CDS should meet with you routinely about documentation issues. You can offer insight on missed query opportunities and share your response rates to retrospective queries, and the effectiveness of the CDS concurrent reviews.
Association of Clinical Documentation Improvement Specialist (ACDIS) (www.ACDIS.ORG)
5 Documentation “Must Haves”
Medical documentation under the MS-DRG system must meet five requirements for quality, compliance, integrity, and reimbursement:
1. Assign patient status (inpatient or observation)
2. Assess the risk in the assigned status (inpatient or observation) to determine services ordered
3. Support medical necessity throughout the patient stay
4. Reflect that the nurse/attending physician frequently monitored/evaluated the patient
5. A discharge and transfer note must reflect a summary of care and a final diagnosis
For example, a patient is admitted to the ER with shortness of breath and dyspnea on exertion. During examination, the physician notes that the patient has a wet cough. The patient’s lab work showed a bnp 20,485/dimer 6,000. CXR revealed pulmonary edema/CHF. The patient diagnosis was congestive heart failure (CHF), and the patient was admitted as an inpatient with a Lasix 80 mg IV BID, 02 2L/NC; The CDS queried the physician for the type of CHF—which was not documented by the admitting physician.
The type of CHF (acute, acute-on-chronic, systolic, diastolic, combined systolic/diastolic, or decompensated) will drive the severity of illness and the DRG. Inadequate documentation of the severity of the CHF will cause case mix complexity, underutilization of resources, inappropriate nurse-to-patient ratio, reduced professional compensation, and incorrect perception of care provided.
Medical documentation under the MS-DRG system must meet five requirements for quality, compliance, integrity, and reimbursement.
10 Tips For CDI Program Success
1. Articulate a Vision Statement. The “vision” of the CDI program should reflect the facility’s goals and desires, including accurate DRG assignment, quality monitoring, and optimal reimbursement.
2. Look to successful programs for guidance. There are several well-established CDI programs in the health care industry. Contact those CDI programs in your area and ask for tips and guidance. Usually, they are more than happy to share information to help you get started.
3. Don’t be shy. Establishing a CDI program is a multidisciplinary team effort, so you’ll have to encourage open communication throughout the team.
4. Get face to face with your team. Electronic or paper communication is acceptable, but especially during the setup and initial phases, personal contact emphasizes the commitment to establish a CDI program.
5. Accept both positive and negative feedback. A multidisciplinary team may uncover problem areas that you hadn’t considered. Be ready to listen and learn, as well as to contribute your ideas.
6. Set short- and long-term goals for your CDI program. A short-term goal can be as simple as piloting your CDI program with one service in the hospital before going hospital-wide. A long-term goal can be broadening your outcome measurements. Goals should be challenging but realistic. Don’t set yourself up for failure.
7. Develop queries for physicians to improve documentation. Include coders and physician advisors when creating the templates. Make sure the query is clear and concise and does not “lead” the physician to document extraneous or incorrect information. Effective queries make a difference in how well physicians respond.
8. Adopt quality measures. Establish measurable outcomes that can be tracked by all stakeholders, including administrators, coders, physicians, and the CDI team.
9. Consider a CDI to help prepare you for ICD-10. ICD-10 requires a greater level of documentation specificity than the current ICD-9-CM coding system. Preparation starts now for the Oct. 1, 2013 deadline.
10. The focus of the CDI program will dictate staffing. The program can be staffed with qualified professionals including HIM coders, nurses, physicians, or a combination of each discipline. If quality indicators, clinical outcomes as well as DRG optimization are important issues, the program may have a combination of HIM coders and nurses. In some programs, physicians conduct reviews and communicate with their peers on documentation issues.
Karen Stanley, MBA, RN, is CDS for Civista Medical Center, Laplata, Md. Karen has 30 years experience in the health care industry. She received special recognition for outstanding performance as a case manager, appeals examiner, and claims auditor at Children’s National Medical Center in Washington, DC. She has been awarded Pediatric Screening Nurse of the Year and was featured in Nursing Spectrum magazine for Kaiser Permanente. Karen served as a medical surgical nurse for five years at King Fahad Hospital in Saudi Arabia. She can be reached at
August 1st, 2011
By Holly J. Cassano, CPC
As a Certified Professional Coder (CPC®) who supports emergency department (ED) physicians, I am often asked how to code appropriately for the physician component of critical care services in the ED. In response, I created these 10 commandments of critical care coding in the emergency room (ER).
1. Thou Shalt Know What Defines Critical Care
CPT® defines Critical Care Services (99291-99292) by three components:
- A critical illness is an illness or injury in which “one or more vital organ systems” is impaired “such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
- A critical intervention involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
Critical care time is “time spent engaged in work directly related to the individual patient’s care,” whether that time is spent at the immediate bedside or elsewhere on the floor or unit. These criteria assume the physician takes an ongoing and active role in managing that patient’s care. Evidence that the above criteria were met must be present in the medical record with the physician’s attestation that critical care was provided.
Some examples of vital organ system failure include:
- Central nervous system failure
- Circulatory failure
- Renal, hepatic, metabolic, and/or respiratory failure
Critical care usually (but not always) is given in a critical care area such as a coronary care unit, intensive care unit, or the ED. Critical care may be provided in any location as long as the care provided meets the definition of critical care. Just because a patient is in the intensive care unit (ICU), does not mean you can code critical care—if the patient is stable, he or she does not meet the criteria for critical care.
2. Thou Shalt Know How CPT® and CMS Definitions Vary
In July 2008, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 1548, which represents the most recent Medicare payment policy update for critical care services (99291-99292). Regarding critical care for Medicare patients, CMS guidelines state, “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”
CMS goes beyond the CPT® description of critical care, adding critical care services must be reasonable and medically necessary … delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.”
CMS gives us several examples that may not satisfy the criteria, either because medical necessity was not met, or the patient does not have a critical care illness or injury and is not eligible for critical care payment:
- Patients admitted to a critical care unit because no other hospital beds were available;
- Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose); and
- Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
Unlike CPT®, CMS not only requires the illness or injury to be of an urgent or emergent nature, but there be the added inclusion of high-level treatment(s) and interventions to satisfy critical care criteria. CMS criteria for critical care are not met if the emergency physician does not deem pharmacological intervention or another acute intervention (intubation, etc.) as necessary, and if the patient only receives coordination of care and interpretation of studies and is admitted or discharged.
To read Transmittal 1548, along with corresponding MLN Matters articles, go to:
www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf.
3. Thou Shalt Properly Document Time
The duration of critical care services for CPT® and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient. Time spent in documenting such activities is included in critical care time. Critical care time does not need to be continuous: Non-continuous time may be aggregated in reporting total critical care time.
To count toward critical care time, the physician must devote his or her full attention to the patient, either at the patient’s immediate bedside or elsewhere on the unit, and the physician must be available to the patient immediately, as necessary. Critical care time also may be spent discussing the patient’s case with staff or discussing with family members (or surrogate decision makers) specific treatment issues when the patient is unable or clinically incompetent to provide history or make management decisions.
Use CPT® code 99291 to report the first 30-74 minutes of critical care and CPT® +99292 to report additional block(s) of time up to 30 minutes each beyond the first 74 minutes of critical care. Critical care time less than 30 minutes is not reported using the critical care codes: Such service should be reported using the appropriate E/M code. For example, for critical care time of 35 minutes, report 99291. For critical care time of 115 minutes, report 99291, 99292 x 2.
The critical care clock stops whenever separately-reportable procedures or services are performed. Time spent performing separately-reportable services, or activities that do not directly contribute to the treatment of the critical patient, may not be counted toward the critical care time.
4. Thou Shalt Know the Key Elements
To report 99291/99292, both the illness or injury and the treatment being provided must meet the critical care requirements, as previously described. Clinical reassessments and documentation must support the critical care time aggregated, and should include:
- a description of all of the physician’s interval assessments of the patient’s condition;
- any impairments of organ systems based on all relevant data available to the physician (i.e. symptoms, signs, and diagnostic data);
- the rationale and timing of interventions; and
- the patient’s response to treatment.
5. Thou Shalt Not Report Critical Care in the ER with an E/M Code for a Medicare Patient by the Same Physician on the Same Calendar Day
CMS Transmittal 1548 specifically addresses this situation for the ED, stating when critical care services are required upon arrival in the ED, only critical care codes (99291-99292) may be reported. An ED E/M code (99281-99285), when provided by the same physician (which includes any physician of the same specialty in the same group) to the same patient, may not be reported additionally. Under Medicare rules, however, critical care may be provided on the same day as an inpatient or outpatient E/M service.
For example: A Medicare patient presents to the ED and receives a level five ED workup (99285). Later during the same encounter, the patient deteriorates unexpectedly and requires critical care services. CMS states that the “same” ED physician can only report either the ED E/M service or the critical care service—not both.
To confuse matters, CPT® allows separate reporting for both an E/M service and a critical care service on the same day; however, CPT® does not distinguish the site of service or which service comes first. Check with your state’s medical policy and your commercial payers’ medical policy on correct reporting of critical care services to maintain compliance.
Some payers may require modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to be appended to the same day, non-critical care E/M service, when coded.
6. Thou Shalt Not Bundle
CPT® and CMS consider several services to be included (bundled) in critical care time when performed during the critical period by the same physician(s) providing critical care. Do not report these services separately. CMS specifies the relevant time frame for bundling to include the entire calendar day for which critical care is reported, rather than limiting the time to just the period the patient is critically ill or injured during that calendar day, as CPT® does.
Both CPT® and CMS bundle to critical care the following:
- Interpretation of cardiac output measurements (93561, 93562)
- Pulse oximetry (94760, 94761, 94762)
- Chest X-rays, professional component (71010, 71015, 71020)
- Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data – 99090)
- Gastric intubation (43752, 91105), Transcutaneous pacing (92953)
- Ventilator management (94002-94004, 94660, 94662)
- Vascular access procedures (36000, 36410, 36415, 36591, 36600)
Any services performed that are not listed above may be reported separately. Physicians are encouraged to document time involved in the performance of separately-reportable procedures. These may not be counted toward critical care time.
For some examples of ER billing and coding go to: http://emcrit.org/190-201/197-ed.billing.htm.
7. Thou Shalt Remember to Code Everything Separately Allowed
The critical care clock stops when performing non-bundled, separately-billable procedures. Some examples of common procedures that may be performed for a critically ill or injured patient include:
92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)
31500 Intubation, endotracheal, emergency procedure
36555 Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
36680 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein
32551 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure)
33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
8. Thou Shalt Know the Appropriate Use of Modifier 25
CPT® does not require modifier 25 when billing for critical care services and/or separately billable (non-bundled) procedures; however, CMS and other commercial payers may require modifier 25 on the same day the physician also bills a non-bundled procedure code(s). Check your payers’ medical policies in your state.
For example, for those payers who specify the use of modifier 25 with 99291/99292: If endotracheal intubation (31500) and cardiopulmonary resuscitation (CPR) (92950) are provided, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately-identifiable service and was appended with modifier 25.
9. Thou Shalt Correctly Report CPR and Critical Care During Same Patient Encounter
CPT® and CMS agree that both CPR (92950) and critical care may be reported, as long as the requirements for each of these services are satisfied and are delineated clearly in the medical record.
CPR encompasses supervising or performing chest compressions, adequate ventilation of the patient (e.g., bag-valve-mask), etc. CPT® does not list a typical time to qualify CPR as a provided service and qualifies it as a separately-reportable service that may be reported with critical care. Remember: Time spent providing CPR cannot be counted toward calculating total critical care time.
10. Thou Shalt Ensure Teaching Physician Criteria Is Properly Documented
Teaching physicians may tie into the resident’s documentation and may refer to the resident’s documentation for specific patient history, physical findings, and medical assessment when documenting critical care. The teaching physician must include a statement about the total time he or she personally spent providing critical care. The statement must include that the patient was critically ill when the teaching physician saw the patient, why and what made the patient critically ill, and the nature of the treatment and management provided by the teaching physician.
CMS provides the following vignette as an example of acceptable documentation: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”
Note: Time spent alone by the resident performing critical care activities in the absence of the teaching physician is not counted toward critical care time. Only time spent performing critical care activities by the resident and the teaching physician together, or by the teaching physician alone is counted toward critical care time.
Bonus Tip: If There Is Food, Critical Care Isn’t Happening
Critical care has passed when a patient’s septic shock has ended, acute respiratory failure has ended, and if other acute situations are well controlled. If a patient is sitting up and eating a meal and drinking regular beverages, that patient is not critically ill. In any case, you can’t go wrong with strong and supportive documentation, combined with medical necessity that encompasses not just an acute diagnosis, but also emergent interventions.
Holly Cassano, CPC, has been certified for more than three years and has been involved in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 13 years. She served two terms as an AAPC local chapter officer and has written several articles for Justcoding.com and has a monthly column devoted to Fighting Fraud, with Advance for Health Information Professionals. She is the coder and physician educator for emergency room physicians at the Cleveland Clinic Florida. You can reach her at email@example.com.
June 1st, 2010
Working with physicians to specify what constitutes as an emergency, and correctly coding emergency room visits with +99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) is enough to frazzle any coder’s nerves.
Anesthesia & Pain Management Coding Alert (Vol. 10, No. 10) takes a closer look at 99140, and clarifies how you should (or shouldn’t) use it with qualifying circumstances (QC).
December 2nd, 2008
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