I landed my first job in healthcare in 1984 as an office manager for a private obstetrics and gynecology (OB/GYN) physician. That also was the year CPT® codes were introduced as general coding requirements for Medicare claims. I thought my role would be interviewing, hiring, supervising staff, keeping books, paying bills, etc.; however, I quickly learned there were a large number of outstanding balances that should have been paid by insurance companies or patients, which led me to work on accounts receivables (A/R).
Learning the Ropes
In talking to insurance companies, I kept hearing things like “not a necessary treatment.” I didn’t know how to argue with that, so I got a set of coding books and started reading. I taught myself how to code, and began networking with others in similar situations.
I later went to work for a neurology practice; and a few years after that, I worked as a practice supervisor doing inpatient coding/billing for nine OB/GYN physicians at St. Mary’s Hospital Medical Group (now Covenant Health System). During that time, I took the Certified Professional Coder (CPC®) exam course and became certified. In 2005, I went on to work at Texas Tech University Health Sciences Center (TTUHSC) with the coding activities coordinator, pursuing charge capture projects for different department clinics. My employer sent me to the AAPC instructor workshop in Orlando, Florida, where I obtained Professional Medical Coding Instructor (CPC-I) designation.
The Best of Both Worlds
I went on to teach the AAPC Professional Medical Coding Curriculum course for TTUHSC and I became unit manager of the Medical Practice Income Plan for Texas Tech Physicians. I assisted all departments/specialties in coding education and coding/billing/reimbursement improvements, and I worked with the transaction editing system and claim scrubber.
Today, I manage a staff of five coders, a billing coordinator (A/R follow up, denials, etc.), a part-time student assistant, and oversee the managed care staff members in the OB/GYN department. We are responsible for coding all services (clinic, outpatient, and inpatient) for six clinic locations, and for all providers, including sub-specialties such as GYN oncology, maternal fetal health, and reproductive endocrinology and infertility, as well as standard OB/GYN. I am still very involved in teaching, as well. I am a member of the TTUHSC executive committee of the 2015 Transition ICD-10-CM Steering Committee, tasked mainly with coder and provider education/refresher in ICD-10-CM. And last year, in anticipation of the 2015 ICD-10 implementation date, I created curriculum that covered several areas of ICD-10 specific coding and taught more than 70 coders.
I love what I do. I compare coding to detective work. I tell my students that a good coder is like a good detective — you track down clues and formulate your answers based on documented facts.
Medicare payers haven’t recognized or reimbursed for CPT® consultation codes (99241-99245 outpatient and 99251-99255 inpatient) for more than five years, but the Centers for Medicare & Medicaid Services (CMS) does extend coverage to telehealth consultations, using dedicated G codes.
Codes describing initial telehealth consultations apply to inpatients, including those in a skilled nursing facility (SNF), or to patients in an emergency department (ED):
G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth [problem-focused history, problem-focused examination, straightforward medical decision making (MDM)]
G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity MDM]
G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity MDM]
Follow-up codes similarly apply to SNF or hospital inpatients, as well as to ED patients:
Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth [problem focused history, problem focused examination, straightforward MDM]
Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity MDM]
Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity MDM]
Per the Medicare Claims Processing Manual, chapter 12, section 190.3.1, subsequent hospital care services are limited to one telehealth visit every three days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.
Whether reporting initial or follow-up services, the provider must meet all three required elements (history, exam, MDM) to bill a particular level of service. For example, to report G0407, the provider must document at least a comprehensive history, a compressive exam, and high complexity MDM. The “lowest” of the three key components determines the billable level of service.
In another example, the provider performs an initial telehealth consult for an SNF patient and documents a comprehensive history, a detailed exam, and high complexity MDM. In this case, the exam is the lowest of the key components, which supports G0426.
Documentation Must Meet Consult Requirements
CMS defines a consultation as “an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient’s problem(s). … The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.”
To demonstrate the service matches CMS’ definition of a consult, documentation should verify the following elements:
1. A request for opinion or advice, and a stated reason to substantiate the need for the service. Per the Medicare Claims Processing Manual, section 190.3.1:
A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record …
Because the consulting provider bills the service, it’s in his or her best interest to document the request as part of the patient record. Specify that the visit is a “consult” (not, for instance, a “referral,” which may signify to the payer a transfer of care rather than a request for a consultation). If possible, ask the requesting provider to put it in writing (email, fax, a note sent with the patient, etc.), and make that part of the record, too.
2. A report from the consulting provider back to the requesting provider. Section 190.3.1 specifies:
After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.
The service is justified only if the consulting physician gives his opinion and/or advice to the requesting provider. Without a report back to the requesting provider, a consultation hasn’t occurred.
The Patient Must Be in a Qualified Originating Site
Telehealth services are available only to patients in a qualified originating site. An originating site is defined as, “the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.”
Telehealth originating sites must be located in a designated rural health professional shortage area (HPSA), located either outside of a metropolitan statistical area (MSA) or in a rural census tract, or a county outside of a MSA. To determine a potential originating site’s eligibility for Medicare telehealth payment, visit the CMS website: www.cms.gov/Medicare/Medicare- General-Information/Telehealth.
Note that a telehealth facility fee is paid to the originating site. You may submit claims for the facility fee using HCPCS Level II code Q3014 Telehealth originating site facility fee.
A Modifier Seals the Deal
Medicare pays only for interactive video consultation services that mimic face-to-face interactions between patients and providers. CMS stipulates that video telecommunications system must permit “real-time communication between … the physician or practitioner at the distant site, and the beneficiary, at the originating site.”
When reporting an approved telehealth service, you must append modifier GT Via interactive audio and video telecommunications systems to the appropriate service code(s). The modifier tells your Medicare contractor that the beneficiary was present at an eligible originating site when the telehealth service was furnished.
For example, for a comprehensive, initial consultation for a hospital inpatient in a HPSA, report G0427-GT.
“Asynchronous ‘store and forward’ technology” (e.g., video clips, still images, X-rays, magnetic resonance images, electrocardiograms and electroencephalograms, laboratory results, audio clips, and text) is covered only in federal telemedicine demonstration programs in Alaska or Hawaii. In cases when you may bill Medicare for “non-face-to-face” telehealth services, report the appropriate code for the professional service with modifier GQ Via asynchronous telecommunications system. In all other cases, as a condition of payment, the patient must be present and participating in the telehealth visit.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Ashville-Hendersonville,
North Carolina, local chapter.
By Marcia L. Brauchler, MPH, FACMPE, CPC, COC, CPC-I, CPHQ
Compliance is a broad concern for provider practices, encompassing everything from proper coding and billing procedures to human resource requirements, patient privacy, etc. When developing a compliance plan, one of the most important decisions you must make is how to allocate your finite resources. By undertaking a risk assessment of your practice’s processes, you’ll better direct your efforts.
My firm created the “Heat Map” for physician practices to identify where to focus their resources — time, money, manpower, and the attention of management, providers, and staff — most efficiently and effectively (see Compliance Heat Map).
The Heat Map is based on historical data related to the number of identified violations for non-compliance and the penalties paid by wrongdoers. Beginning with the raw data, we examined:
Scores are based on a scale of 1-5, where 5 represents the greatest probability and risk. The upper right quadrant of the Heat Map represents the highest probability you’ll be audited and the most severe penalties for non-compliance.
For example, we scored being audited for the Americans with Disabilities Act (ADA) at 1 (low probability). But if you are audited, the failure to comply scores at 5 on our scale. In 2012 there were 72 lawsuits commenced for failing to comply with the ADA, with total fines and penalties of a whopping $5.4 million.
Top Compliance Priorities for All
The highest frequency, highest severity categories in the upper right quadrant of the Heat Map for any practice should include HIPAA, Medical Records, and the False Claims Act (FCA), as shown in our example.
We discussed HIPAA compliance, and compliance with medical records rules and regulations, in the series of articles “Answer Common HIPAA Questions,” which ran last year in Healthcare Business Monthly. Using the Heat Map as our guide, we will explore additional topics in the coming month, beginning this month with the FCA.
The What, Why, and Where of Compliance
When discussing compliance issues, generally, I ask: WHAT is it? WHY does it exist? WHY should you care? And, WHERE can you find more information?
What Is the FCA?
The FCA is a federal law prohibiting a practice from submitting false or fraudulent claims to the federal government. This includes claims for payment of healthcare services paid by the federal government, most notably for the federally funded Medicare and Medicaid programs.
Why Does the FCA Exist?
Congress enacted the FCA in 1863 because it was concerned that product suppliers during the Civil War were defrauding the Union Army. The FCA stipulated that any person who knowingly submitted false claims to the government was liable for double the government’s damages, plus a penalty for each false claim.
There are actually two FCAs: a civil act and a criminal one. Penalties for violating the civil FCA are severe, ranging currently from $5,500 to $11,000 per violation. Plus, the federal government tacks on an additional penalty of three times the amount of damages suffered by the program. Each instance where a practice fraudulently bills the federal government for an item or a service counts as a claim, so fines can add up quickly.
The government’s return on investment for enforcing the civil FCA is huge. For every $1 it invests on enforcement, it receives $7 in recoveries. To date, the Office of Inspector General (OIG), which enforces the FCA, has recovered upwards of $30 billion for government medical programs from providers of all types.
You can violate the FCA by:
For example, a physician who knowingly submits a claim for healthcare services for a patient who doesn’t exist, never received the services, or for whom the services were not medically necessary is in violation of the FCA. A false claim could also be triggered when a practice bills for procedures over a period of days when all of the services occurred during one visit.
The difference between the criminal and civil FCA is “knowledge.” You can’t violate the criminal FCA, and potentially serve jail time, unless the government can prove you submitted a claim or caused someone else to submit a claim that you knew to be false. Under the civil FCA, however, knowing includes not just actual knowledge, but also instances in which a person acted in deliberate ignorance or reckless disregard of the truth (in other words, the person should have known the claim was false). This makes it easier for the federal government to bring a civil FCA case against a practice than a criminal one.
Several situations may arise in your practice that could result in a violation of the FCA, some of which might not be obvious to you. For instance, non-physician providers perform many functions and services in a typical practice. If one uses a physician’s provider identification number without meeting the incident-to criteria, the practice could receive a higher reimbursement rate than is allowed. This overpayment, if not returned to the federal healthcare program in a timely manner, is a violation of the FCA. Your practice should have a strict policy against inappropriate use of physician provider identification numbers by non-physician providers.
Another area that can result in an FCA claim is granting “professional courtesies,” which describe a number of practices. The traditional professional courtesy is when a provider waives all or a part of his or her fee when healthcare services are provided to other providers, staff members, or their families. More recently, professional courtesy includes waiving coinsurance obligations or other out-of-pocket expenses for providers, staff members, or their families — commonly known as insurance-only billing.
There are circumstances in which waivers are permitted, but this should never be done routinely. Waivers should be well documented, and based on financial need. To do otherwise risks violating the FCA, and possible violation of the Anti-kickback statute (a great example of one set of circumstances and actions that can result in violations of multiple laws). Here again, your practice should adopt a strict policy regarding these professional courtesies (ideally, prohibiting them).
Why Should You Care?
A unique provision within the FCA allows people who are not affiliated with government agencies to file actions on behalf of the government against practices for potential violations of the law. These people, commonly known as whistleblowers, expose misconduct and alleged dishonest or illegal activity occurring in an organization (often their employer). Whistleblowers can be office staff, patients, physicians, competitors, etc. If a whistleblower’s lawsuit is successful, he or she is entitled to keep a percentage of any monies the federal government recovers from the practice.
Under the FCA, a whistleblower has to prove the physician practice (or billing company) submitted a claim, or caused someone else to submit a claim, to the government containing false or fraudulent information, and the practice or billing company knew (or should have known) the claims were false. Whistleblowers are protected under many laws. Retaliating against a whistleblower can get you into even bigger trouble.
Where Do You Get
More Information about the FCA?
One of the best resources for more information about the FCA is the OIG’s website: www.OIG.hhs.gov.
Still to come: We will cover topics on the Heat Map in descending order: Occupational Safety and Health Administration regulations compliance, and human resource regulations compliance.
Marcia L. Brauchler, MPH, FACMPE, CPC, COC, CPC-I, CPHQ, is the president and founder of Physicians’ Ally, Inc., a full service healthcare company, where she and a diverse staff provide advice and counsel to physicians and practice administrators, and education and assistance on how best to negotiate managed care contracts, increase reimbursements to the practice, and stay in compliance with healthcare laws. Brauchler’s firm sells updated HIPAA, OSHA, & Compliance policies, procedures and online trainings at www.physicians-ally.com. She is a member of
the South Denver, Colorado, local chapter.
Focus on Reporting as Hospitals Avoid Infections
By John S. Aaron, Jr., CPC
Methicillin-resistant Staphylococcus aureus (MRSA) is an infection caused by a certain strain of staph bacteria resistant to common antibiotics. Individuals are more prone to acquire MRSA while in the hospital for surgery or other treatment. Over the next few years, the Centers for Medicare & Medicaid Services (CMS) plans to increase penalties on hospitals that have the highest record of infections and
injuries, to include MRSA. This program will affect an estimated 700 hospitals.
In 2007, the American Medical Association (AMA) introduced new procedure codes for MRSA testing:
87640 Staphylococcus aureus, amplified probe technique
87641 Staphylococcus aureus, methicillin resistant, amplified probe technique
Since then, more affordable methodologies have come about, such as cultures by nasal swab:
87081 Culture, presumptive, pathogenic organisms, screening only
Reporting vs. Reimbursement
Most codes are created for reimbursement purposes, but there are also codes meant for reporting purposes only. When a patient is tested for suspected MRSA colonization, coding guidelines direct us to assign V02.54 Carrier or suspected carrier of methicillin resistant Staphylococcus aureus (ICD-10: Z22.322). If a claim is filed with this diagnosis prior to receiving a positive on a patient’s labs, upon denial by Medicare, the patient should not be billed. You should report the service, however, because these measures may qualify hospitals to participate in pay-for-performance programs when Medicare ultimately factors in rates of MRSA infection.
If a claim documents an infection due to MRSA, and that particular infection has no “combination code” (including the causal organism), assign the appropriate code to identify the actual condition, along with 041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site (ICD-10: B95.62).
In such a case, Medicare should consider the service to be necessary and reimburse under the patient’s outpatient Part B coverage. If the testing occurs during an inpatient stay, Medicare should reimburse using the diagnosis-related group method.
Medicare will be including the rate of MRSA infections in the Hospital-Acquired Condition Reduction Program. Coders have an opportunity to offset any losses experienced by providers, with continued documentation of infection control programs that may justify later rewards.
John S. Aaron, Jr., CPC, is a member of the Northbrook, Illinois, local chapter and has served as a chapter officer in recent years. Aaron has 15 years of billing and coding experience, and he recently established ClaimChek — a billing service with a focus on patient advocacy. You can follow him on Twitter at: @ClaimChek.
Tell us a little bit about your career — how you got into coding, what you’ve done during your coding career, what you’re doing now, etc.
I have a degree in communication/journalism and have been a writer, in one form or another, my whole career. I started out in newspapers and trade publications, and then moved to technology publications. About 10 years ago, the newsletter company I worked for was sold and my new employer asked if I was interested in writing about medical coding. I said yes, mostly to keep my job, but it turned out that I loved the coding world.
I become a Certified Professional Coder (CPC®) soon after making the transition into coding, and have since earned my Certified Urology Coder (CUC™), Certified Physician Practice Manager (CPPM®), and Certified Evaluation and Management Coder (CEMC™) credentials through AAPC.
I am now managing editor for Healthcare Handbooks at The Coding Institute. I have written Urology Coding Alert for 10 years, Practice Management Alert for nine years, and I manage several other publications. I also audit, lead provider training, and speak at national and local coding events.
What is your involvement with your local AAPC chapter?
I have attended meetings for a few years and began speaking at the annual chapter conference and other monthly meetings last year. I am the vice president of the Rochester, New York, Flower City Professional Coders chapter.
What AAPC benefits do you like the most?
I love the ability to network with coding professionals, especially at local chapter meetings and conferences. Hearing how coders handle work-related situations and talking with others about their challenges and ideas are invaluable takeaways. The national and regional conferences are a ton of learning and networking rolled up into a few days, which I love!
What has been your biggest challenge as a coder?
Because I write about coding on a national level, my biggest challenge is learning how payers do things differently. No two payers’ policies are alike. Learning those nuances to produce how-to coding content that helps all my readers can be challenging.
How is your organization preparing for ICD-10?
The Coding Institute has been producing specialty-specific ICD-10 coding articles, as well as other ICD-10 products, for several years. We are trying to help our readers learn exactly what they need to know for whatever specialty they code. I took my ICD-10 proficiency assessment (and passed!) about a year ago, and much of our staff has gone through training, as well. We want to be sure we know all the ins and outs of ICD-10 so we can pass that knowledge on to our readers.
If you could do any other job, what would it be?
I would probably always do some sort of writing, but my dream job would be to open a bakery that serves folks with food allergies. My son has multiple life-threatening food allergies, and busy families like ours could really use a place to get quick treats for things like school events and birthday parties. I enjoy baking special treats for my kids, and would love to make a living helping other food allergic families.
How do you spend your spare time? Tell us about your hobbies, family, etc.
Most of my spare time is spent having fun and making awesome memories with my husband, Eric, and our two kids: Riley, 11, and Addison, 4. I love to read, bake, decorate cakes, and do floral arranging. I volunteer as a board member at my daughter’s preschool and I am a leader in my son’s Cub Scout Pack. I also enjoy serving as a lay minister and as my church’s Foodlink event coordinator.