Urology Coding Alert

Presented by Kristine Eckis

The following supplement to Urology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Kristine Eckis is President of The Bottom Line Medical Administrative Consultants, Inc. "Bottom Line" celebrates its 10-year anniversary in 2005. With 26 years of combined medical and legal experience, Kristine consults with medical practices nationwide providing evaluations and recommendations for operational improvements and accounts receivable management. She also assists with practice start-ups and provides coding education and chart audits, both on and off-site. She is a Board Member of the American Association of Healthcare Consultants and a member of the National Association of Healthcare Consultants and AHIMA. Kristine has been accredited by the American Academy of Professional Coders as a Certified Professional Coder since 1996.

Thank you, good afternoon everybody.  During the past 10 years, I have evaluated numerous practices and I have presented hundreds of coding seminars and at the various practices or through interaction with the attendees, I am always amazed at the amount of money that practices are losing and it really bothers me.  I do not like to see clients leaving money on the table.  The other thing is this loss repents pure profit, you have already covered your overhead, so anything that you are leaving out there is just absolutely profit and this is either due to incorrect coding for the service or the procedure that is being provided, or it is failing to bill for it all.  There are a lot of services that we provide that we do not know we can bill for.  So the distressing fact is that even today I continue to uncover the same types of problems in medical practices.  So I am glad to have this opportunity to share some of the information I found with you and I hope you will discover at least a few ways to improve your bottom-line and to capture all of the revenue that you are illegitimately entitled to.  So we will go ahead and we will get started. 

The first topic I want to address today is telephone management and it has been a source of controversy.  When the codes first came out in 1995, AMA presented them.  A lot of the physicians, especially the ones that had been in practice for several years, said there is no way that I am going to bill my patient for a telephone call.  But on the other hand, we are providing a lot of services on the telephone especially now, ten years later, we are giving prescriptions, we are talking to therapists, nutritionists, pharmacists.  We are discussing the patient's care with other physicians.  We are talking to the patients.  So the doctors are spending a lot of time on the phone and especially for those that are interrupted in the middle of the night by the ER with the emergencies about their patients, and they are rendering a professional service and then going back to sleep. 

The nice thing is they can be reimbursed for this.  A lot of them do not know it and a lot of the ones that found out about it decided, hey I am going to go ahead and take what I have coming to me, and it makes it a little nicer for them they do not.  Some of them, they do not mind getting the phone calls anymore because they know they are going to get paid for them.  So these codes that were introduced on slide 2 were brief, intermediate and complex.  There were codes 99371, 72 and 73 and as you can see on this form.  It can be a call between the physician and the patient or for a physician to a physician for coordination of medical management.  For instance, if your primary care provider and you have had to refer a patient to an oncologist for treatment of cancer.  There are times when they have to call and they have to coordinate the care.  It can also be with coordination of medical management with other healthcare professionals and this does include pharmacists. 

So if you are filling a prescription on the telephone, as long as your physician is involved - and that is the key - the physician has to talk to the patient or the physician can talk to the patient and turn the file over to the nurse and say, call this script in.  As long as he has talked to them and been a part of the call, he can bill for the service.  It has been especially a nice procedure for pediatricians and OB/GYNs because they get so many calls and lot of my pediatrician clients say that it absolutely eliminated nuisance calls, so the Mommies will not call the doctor at 2 o'clock in the morning to discuss the diaper rash - they'll wait. But at any rate, the key to billing for telephone management is to make sure that you inform your patients that you do so.  They need to know that those codes did come out in 1995 and that they will be charged a nominal fee so that they are not surprised when they do get the bill.  You could post a notice in your reception area on your letterhead, and you might want to include the fact that you are trying to help them.  That actually by giving them a service on the telephone, you are saving them the time required to come into the office, to get the baby sitter to take off of work, and office visits are much more expensive than a telephone call. 

So there are ways to present this to the patients where they actually are happy to pay for the telephone service and not have the other inconveniences.  You might want to close your notice about this with the statement such as, we will continue to work with our patient and our managed care plans to reduce healthcare costs and provide quality care, and what this is doing is showing them that you are trying to help them.  It is all and how you approach the topic. 

So on slide 4, I give you some examples.  Now these are rates that some of the insurance plans were paying back in the year 2000 and 2001 in Polk County Florida and no matter where you are in the country, there are plans that pay and there are plans that do not pay and they vary.  So what you want to do is you want to go ahead and contact the managed care plans that you participate with and see which ones do pay for these services and how much they pay.  Several of these, like Up & Up, Southcare, Evolutions and Beechstreet, these are plans that are right across the country.  They are just not limited to Florida but you can see some of the reimbursement that you could get.  First Health will pay $10.37 for 99371, that is what I would consider for a prescription call in.  Southcare, which used to be Principal, they will pay $14.  On slide 5, I give you an updated grid for some of the reimbursements that are being paid in the Orlando area and you see Cigna is added there and Southcare in Orlando pay $17.65 for the lowest fee. 

So I do not know why anyone would want to not bill for this service that they are providing if there are payers willing to pay it, because these reimbursements add up over the year.  I mean we call prescriptions in all day long, certain specialties make different types of calls everyday.  So I believe you should take advantage of it and bill for it when it is warranted.  The one thing that I do want to say lastly about telephone management is of course, what it is new and no surprise:  Medicare and Medicaid do not cover this.  A lot of patients practices will say to me well, then I am dead because my practice is mostly Medicare patients, but I can tell you can still add a little bundle to your bottom line by billing for these codes.  Medicare does not allow you to use the advanced beneficiary notice and have the patient sign it that is not a service; in other words, you cannot use the ABNs for this.  You cannot tell the patient that is a non-covered service and make the Medicare patient pay it.  It is strictly not allowed at all. 

Now those codes came out ten years ago.  It is 2005 and what I found is everything is just clamping down and doctors' fees are being reduced, their malpractice is going up, their overhead is increasing.  So they are starting to look at billing for any service that they provide because they know they cannot afford not to.  Well that is coming around.  We just had come out in 07/2004 an opportunity to bill for online services and there are lot of our physicians that are rendering services online talking about prescriptions or just getting back to a patient online.  As long as it is an established patient, as long as your physician provides the evaluation and management and documents and prints it out and stores it in the patient file, he can bill for this service.  And just for your information, Blue Cross and Blue Shield pays $29 for an online service in Highlands County Florida, that is a very rural area where Seabring is located.  So even Blue Cross is paying for this, so there is a great opportunity as you start your online services which we are all kind of gravitating to where we can bill for that service. 

I want to mention nurse visits because I found that nurse visits are somewhat abused in some practices.  Any time you have a service performed by the nurse and she bills for it, it must have been under the direction of the physician and he must have documented it in the medical record:  "I want Ms. Jones to return and follow-up with the nurse for the next two weeks once a week or three times a week or whatever he wants."  But he needs to put in there why he wants the patient to come in and follow-up with the nurse, and then when the patient does follow-up and the nurse takes care of the patient, then she goes in and documents the date and what she did, the specific purpose.  You know that the physician had asked for this. 

So this is not a random hit and miss visit; you can just have people coming in saying, I want a blood pressure check and there was nothing in the file that warranted that this was necessary by the physician.  You just cannot be billing for the services without qualifying it.

And now on moving onto slide 9, injections and medications.  I have found so much confusion.  I will go to offices and they will bill for the injections but they will not bill for the administration.  They bill for the medication only or they bill for the administration of the injection and they think that is including the medication, which is not. There are always two charges.  For instance 90782 is an administration of a therapeutic injection and some of the examples of the therapeutic injections are listed there, such as vitamin B12 or Benadryl, Demerol.  So if you are going to inject the patient, you will bill 90782 and you will also bill the J code for the particular type of medication. 

I wanted to point out to you that this year Medicare has made a change and instead of using 90782 for your administration of therapeutic injection, they are insisting that you use code G0351.  It was effective 01/01, and if you have been billing any medication injection since 01/02 Medicare with 90782, you will need to go back and go ahead and re-bill them.  You do not need to wait for the rejections because they are not going to pay you.  They say they are going to deny all of the 90782s and make you re-file, so that is an important change this year that you want to make note of. 

Then we have administration of antibiotics.  Again, 90782 is the most common administration of injection code, and I am finding that some offices are using the administration of a therapeutic injection for an antibiotic or for a vaccination or for an allergy shot and their claims are going to get kicked and the reason is, it does not link to the particular type of medication.  So if you are going to give an antibiotic such as ampicillin, then when you administer the antibiotic, you are going to use code 90788 plus the J code for the ampicillin.
 
Now, we have a separate set of immunization administrations for vaccination toxoids, 90471 and 72 are for one vaccination and then each additional.  Then, 90473 and 74 are the same thing except they are for oral administration.  On slide 11, we have got four new codes just to make it a little more confusing.  So CPT has brought these codes out and it is really important to take a look at them.  90465 is immunization administration under 8 years of age when the physician counsels the patient or family member, first injection per day, and of course 90466 is your add on code for each additional vaccination. And then they have 90467 and 68 just as we did on the previous slide for the oral route.  But on slide 12 if you look at this with me, 90465 is the immunization administration under 8 years of age, has relative value units assigned at 3.7, whereas 90471 - which is the same exact service but it is for children and adults over 8 years of age - only has 1.9 RVUs.  So what we have here is an opportunity to collect more money when we use the proper code for those children that are 8 years and younger.  It pays approximately $20 more than 90471.  So we want to definitely be paying attention to age and maybe put these on the encounter form and put the age next to it so that we do not miss out on that additional $20.  We do not want to just keep on using 90471 because we are in the habit. 

On slide 13 I gave you some dosages of J codes, and the reason I am listing dosages, it does not really have anything to do with the administration of them.  What I am finding is there are a lot of practices losing money because they are stocking the medication and then when they provide it, the J codes are for a specific unit of medication.  So if you see the Depo-Provera J1055 is for 150 mg.  What happens when you give 300, you will need to use J1055 x2.  I do not know that that would ever be the situation, but it certainly could be with the ampicillin.  The point is, we need to list our milligrams, the units assigned for that J code, so that we know if we exceed the dosage that we have to multiply the J code x2 on our claim form in order to be adequately reimbursed.  There is a high potential for lost revenue there. 

Working in emergencies - I like this like I like telephone management.  Again, almost all the payers are paying for this and if you work in a patient into your schedule for the day - you've got a comfortable schedule, it is the usual - and you work that patient in.  What happens is either your nurse does not get to go to lunch or she has to stay after hours usually, so does the front desk, because they have got to be able to check the patient out.  This is inconvenient and there is increased overheads, so why should not you be paid a bonus for working that patient in, rather then sending them to the emergency room?  I personally do not think they are paying enough, because when you work in that patient you save the patient going to the emergency room, a five hour late much, and a much higher bill for the facility and the physician. 

So I would like to see these reimbursements increased but at least they are there; so if you work in the patient on your schedule, you will bill for the office visit no matter what type it is.  You will bill for any procedures that you provide, maybe to have some sutures, plus the office visit and then on top of that you will bill 99058, and you do not need a modifier with that, it is just all on its own and you will be paid for all three services.  Your bonus should be paid for the office visit and you will be paid for any procedures you did in the office and again for your information, I have listed some reimbursements there from North Carolina and Florida, Highlands County Florida, Seabring, Blue Cross and Blue Shield is paying it now.  Blue cross pays $26 in addition to your regular office visit. 

And it may seem silly, but hospital discharges on side 15 - again what we have got here is 99238 - that is what we commonly use.  And I still find practices that do not know there are two discharge codes.  They are just not taking the time to get updated and every little penny counts.  So 99238 is less than 30 minutes spent to discharge a patient and it has 1.87 relative value units.  99239 - the RVUs increase to 2.55, and if you translate this into fees, at least on the Medicare fee schedule, you are talking about a $50 difference in reimbursement.  So, it is really important that our physician start being cognizant of time and how much time they are spending on their services.  It just takes a little bit of time to get themselves in a good habit and to start being aware of how much time they are spending. 

The other interesting thing is to qualify for hospital discharge, you need to document your time. Your time includes instructions to caregivers, preparation of the discharge records, referral forms, prescriptions - and it does not have to be continuous, it can be on and off and then you know the total amount of time added together is what you spent.  So physicians need to know that as well as the face to face goodbye, at the hospital there is a lot involved with it, so have them pay attention because for every discharge over 30 minutes that is going to be $50 more. 

We have preventive counseling and there is some confusion with that.  Preventive counseling is preventive medicine or a risk factor reduction counseling at a separate encounter for the purpose of promoting health and preventing illness or injury.  There cannot be a problem already established.  If you are counseling them about something that is already a problem then you cannot use the preventive counseling codes and those codes are 99401 through 99404 and they are based on 15 minute increments.  So you would use 99401 for 15 minutes and 99404 for an hour.  Again, do not confuse problem counseling with patients that have symptoms or established illnesses, that will be addressed some place else.  Examples of preventive counseling would include family problems, sexual practices, injury prevention, diet and exercise, substance abuse, it can be dental health, it can be a wide variety of problems that we want to avoid.  It could be a mother bringing a teenager and that you know starting to hang around with a crowd that she is a little worried about, and she does know how to explain what happens when you get out there and you start being promiscuous and she wants her daughter to know about STDs etc.  So she bring the daughter into the gynecologist and he or she explains to the child what can happen and gives them some handouts - that is what we are talking about there.  So it is another area where you would want to take advantage, and again there have to be separate from the normal E&M codes.  If you bill for an office visit and the preventive counseling on the same day you are not going to get paid. 

Now we move to draws and specimen handling.  Labs - we commonly outsource our labs and just do the draw in-house and prepare the specimen for collection.  Some offices do not even know you can bill for the draw, and there are a lot more that are billing for the draw but they do not know that you can bill for the specimen handling from the physician office to the laboratory.  That of course is your nurse taking the time to prepare the paperwork and package everything appropriately.  So you want to bill for both of those if you are doing draws and sending out lab work. 

The other thing that I have listed here is that effect of 01/01, Medicare is no longer requiring G0001 to be used for the draw.  They dropped it and if you billed a draw with G0001 after 01/01, it is going to be denied.  They want to use the regular code now 36415. 

There are a lot of times where physicians spend an abnormal amount of time beyond the usual to prepare special reports and they can code for this service with 99080, and again reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form. 

Now I would like to talk about undercoding because we are losing a lot of money.  I think more physicians are undercoding then overcoding and most of the reason is, they feel 'I would rather under code and know that I am not overcoding and just lose the money rather than have to worry about getting audited.'  But undercoding can get you flagged for an audit just as easily as overcoding, so why not code accurately and not undercode and lose extra money that you do not have to lose.  We just can afford to leave that money on the table.  So if you look at slide 20, we have got a little bell curve here for you.  It is for a primary care physician.  It is like the standard or typical bill curve nationwide for a primary care physician, new level, new patient visit. 

You will see a level 99203 is the highest and then the next highest level of service would be 99202 followed by 99204.  Depending on your patient mix this could change, so just because this is the typical bell curve, it should not worry the physician if his bell curve shows more 99204s, because it could be that he is in an area where he has a lot more Medicare patients who have a lot more problems and medical decision making is increased.  So, your locality and your patient mix can make your bell curve deviate.  The main thing is, you want to find out what your bell curve is and then kind of keep an eye on what your trending is.

So on slide 21, we have Dr. Undercode, and you will see most of his levels are 99202s.  I want you to think about something.  If you spend 20 minutes taking care of a patient and you document poorly, so say you coded a 99212.  The insurance company might pay you $70 for your services.  If you are to take just the extra two minutes that might be required to fully document what you did, you could conceivably more than double your reimbursement, and of course you are legitimately entitled to it.  I would never suggest to game the system in order to do anything that you should not be doing.  The point is all two often we are in a hurry and we get going and we are careless and we leave things out of our documentation and the documentation is what supports the level of service.  So in the mean time, you would have been paid $3.50 per minute for those first 20 minutes that you documented.  But if you had taken those two extra minutes, you would have been paid $35 per minute to completely document and have your chart filled out properly.  So the solution is, take the time to fully document what you did and why you did it, according to the documentation guidelines.  And I have got slide # 24: by undercoding you lose a substantial amount of revenue and I just want you to give this some thought.  If you look at the difference between the 99212 and the 99213, it is approximately $25, and I'm basing this on Medicare fees, everyone's fee schedule is different but we are just going to use that as a basis.  Our most common codes are usually 99213 and 14 and the difference between those two codes is $45; and then if you under code by two levels - say you undercode and you have a 99212 when you really had a 99214 but you did not document the 99214, you have lost $65, and that is just for one visit. 

So if your doctor had a tendency to undercode, and he sees 30 patients a day, and say about half of them were undercoded at an average of $35 dollars per visit.  That would be a loss of $525 a day, which would be $1125 a month, which would translate into a $132,300 a year.  Just by undercoding one level, half the patients he or she sees during the day and again, that is pure profit.  He just gave it away, so it is better to take the time find out what it is that we are not sure about on our E&M coding, and code what we did so we capture that revenue. 

I am moving onto slide 25, the evaluation and management documentation and this coincides kind of with the undercoding that we were just talking about.  In evaluation and management our documentation is crucial and we usually code our services based on the level of history, the level of exam and the level of medical decision-making and there are components within each of those.  There are three components in history, the history of present illness, the review of systems and the past family and social history.  Those three components together make up our level of history.  What I have found: the biggest culprit in our documentation of history is that the review of systems is missing, or the doctor says, well I did review of systems is right there in my exam.  But the coding guidelines will not let an auditor count the review of systems and the exam as two different items.  So if you are counting on your examination to be your review of systems, then you are really hurting yourself because they are going to say you did not have one.  And when you do not have the review of systems, obviously your level of history is going to be very minimal. 

Also regarding the review of systems, we have 14 systems.  The eyes were broken out - three or four years ago, they made eyes a separate system.  So we have a total of 14 systems and a lot of doctors are still using HEENT and that is okay, I am not saying they cannot use it, but it would be better to break out eyes from ears, nose, throat, because depending on who is auditing, they may miss that system and one system can throw your whole code off.  The other thing I want to mention here that has been a sore spot with physicians. They tell me, well this is ridiculous.  I am not going to document a complete review of systems every time.  First of all, obviously if it is a new patient, you would need a comprehensive review of systems; but if it an established patient you are going to do review of systems pertinent with the presenting problem.  But if they do not want to dictate all of the different systems that they addressed, they can say, "the review of systems is consistent with findings on 01/17 with the following exceptions." And then they can say 'none' or they can list the exceptions, and then your auditor would go back to 01/17 and look at the level of review of systems there and go ahead and count it.  So that is a lot easier than going through each system and having a separate sentence for each one, they can do this.  They can also refer to the clinical intake sheet.  A lot of times we have NAs or nurses take the review of systems; or the patient fills out a form and it's in the file with all of the answers.  And the doctor will go to it and he will review it, so all the doctor has got to say is that he reviewed the clinical intake review of systems and then he initials and dates it, and that will count as his review of systems as long as he referred to it and it is signed and dated to show that he actually did look at it.  So it is not as time consuming as it seems.  It is just a matter of knowing what works for you and then getting in a good habit. 

The other problem with evaluation and management - I am giving you the two biggest problems I have found - is with the medical decision-making.  Again, we are talking about our level of service and we get to it by establishing a history, the exam and the medical decision making.  Medical decision-making is just like history.  There are three components.  We are dealing with the number of diagnoses, the amount of data reviewed and the overall risk. 

On slide 27, the bolded area is amount of data reviewed.  Doctors are all always having these patients coming in with baggies of their medications and they come in with their lists showing all their blood sugar readings every morning or their weight - what was their weight three times a day.  They bring in all kinds of things.  They go to the ER and they bring information from the ER, they will come in with the lab or an x-ray or an MRI, because they have been referred from some place.  There are just numerous items that the physician reviews, but if he does not document it, it means nothing and then it decreases the level of medical decision-making, which hurts him, because he is not going to reach the level he needs to be at.  Or he might be counting it in his head and thinking this is a 99214, but because he did not document it, it is going to make it look like he overcoded. 

So on slide 28, I give you a list of all the different types of things that the doctor may review and especially in primary care, a lot of times we have the patients go and have lab work done before they even arrive.  So it is important that the doctor go ahead and document what he reviewed: you know, a summary of the labs, 'they are all within normal range with the exception of such and such.'  But the point is that they need to document that and of course they need to initial the reference data if it is in the file. 

Now on slide 29.  I got a situation here I'm in the ER, I'm the physician and I have been taught to code by history, exam and medical decision-making, but my patient is unconscious and he cannot tell me what is wrong.  He can not give me a history and there is nobody with him that knows him to help me understand anything about a history.  So in my documentation, my history is completely missing.  Yet I had a comprehensive exam and a comprehensive medical decision making.  So what would the appropriate code be  in this circumstance?  If you went by our rule, he would have to fall back and only bill a 99281, but this is an exception to the rule.  And in this case the physician could bill 99285, which is the highest level of service for the emergency room, and the only thing he has to do to justify this is document why he was unable to obtain a history from the patient.  And if he has got that documented, he will be within the guidelines and he will be paid for a 99285 and he would not have to worry about over coding. 

I have here 'minimal physical' because I that is a kind of how I refer to them.  But what do you when you have a physical that is not the full comprehensive version of a physical, you just fill out a few forms and you listen to the heart.  Some are more detailed than others but with some of them it is just a matter of signing of form or two and listening to the heart and lungs. 

So how do you code those? Well you are going to use preventive medicine codes because these patients coming in for these types of services are not sick. They are here for a preventive service.  So you would use your preventive medicine code according to age.  Those are the 99380 and 99390 series.  They are new and established and they are calculated according to age, it's very easy.  And then you would apply, if it was not be a full physical, you will apply modifier 52 to it and modifier 52 will inform the payer that a preventive visit was performed but the service was reduced from the established guidelines. Of course we want to be honest, that is why we are using modifier 52 to tell them that we did not do a comprehensive physical.  But what is important here: Do not reduce your fee and the reason you do not want to reduce your fee is that some payers will apply a formula to whatever you bill and automatically reduce it.  They may reduce it by 20 or 25%.  But there are other payers out there, they do not care about modifiers 52 and whatever you bill they are going to go ahead and pay it.  So you do not want to reduce you fee and then have it doubly reduced.  So that is important with your physical.  You do not want to lose that money.

I have got little slide here about staying up to date with industry changes because industry changes don't just happen at the end of the year.  They happen throughout the year and if you do not pay attention, you could lose money.  One of the newer items - I do not know how many of you are aware - but ICD 9 codes are now going to be updated twice a year.  Last year in October, the new ICD 9 codes came out and we were required to use them right away.  And now this is April, you want a calendar in like the end of March to be watching for the changes, because they are going to update them again now.  I do not know we will have to buy new coding books.  Everyone has been asking me that, but they are going to be updated twice a year now and failure to update your ICD 9 codes is going to result in rejected claims and then increased overhead from chasing the money and re-filing.  Like I mentioned before, the online consultations, the new code 0074T it went into effect in 07/2004 right in the middle of the year. So you want to make sure that you are paying attention to the updates because it would be a shame if you have been doing online consults since July and you just found out about it today.  You could go back track with some of your payers, but you just don't want to be losing income that you are entitled to. 

Now I have a slide here # 32: IPPE physicals and this is an initial preventive physical exam for Medicare patients.  Most of you I am sure know that Medicare does not cover routine physical exams or annual exams, but this year they introduced a new benefit for beneficiaries and as of 01/01, anyone that becomes a Medicare beneficiary on 01/01/05 or after can get a physical; but it has to be scheduled within six months of their initial date of coverage and it will include a physical and an EKG.  On side 33 I gave you the Florida Medicare rates there and the codes, because the coding for this is of course the Medicare codes, the HCPCS level-II codes.  They one should use G0344 for coding the exam and they are paying $95.86 cents for that in Florida and instead of using the 93000 series for your EKG, when it is regarding an initial physical for this purpose, you are supposed to use code G0366 for the EKG and they will reimburse $26 dollars and 6 cents.  So in Florida, if you are paying attention to your new Medicare beneficiaries and you are catching it, you have an opportunity to schedule them for this service and collect the $121.92.  So it will be important to start watching them and if you are a  specialty that provides this type of care, make sure that you are capturing this revenue. 

Now we have admissions.  Admissions have been a problem simply because some offices do not pay attention to what is going on with their patients.  If the physician takes the patient in the back and there is an office visit, and then he decides to admit that patient, do not let the patient go out with the encounter form to the front desk and check out and enter that visit into your system.  Because if you are billing everyday like you should be, the next morning that visit is going to go into the payers and you are going to be paid for the visit and you are going to lose the admission and of course the admission pays a lot more. 

So in a circumstance like that you want to pull the encounter form and void it or put on it 'admitted' and make sure you do not bill for the office visit and instead bill for your admission.  The same thing applies to observation care.  If you have someone in the office and you admit him for observation, you will bill for the observation instead of the office visit.  But then we have a reversal here.  If you have an office visit and you decide to admit the patient for surgery and the surgery is different and your decision for surgery was made that day, then you are going to bill for the office visit because you are entitled to be billed for the time it took to assess that the surgery was necessary.  Normally that is included in what we call the global, the preop, the admit and the actual service provided and then postop. But you will use modifier 57 any time that your office visit resulted in an admission for surgery to make sure you get paid for that office visit.  Some providers are under the impression that that is still considered a preop and it is not. 

Also some of the questions I get, here is one on slide 35.  If the orders are called in to admit the patient late in the evening and the physician does not see the patient, he just talks to them on the phone, talks to the ER or whoever at the hospital on the phone, and then he comes in the next morning and sees the patient.  Can the physician bill for the admission, physical and history on the date of actual admission - which was the evening prior - and then bill the next morning when he sees the patient as a subsequent visit?

No.  CPT states that the initial hospital care codes are to be used to report the first hospital inpatient encounter by the admitting physician.  It has to be face to face, that admission code is when your physician saw them.  So this is quite common, I have found this in many many practices where they think it is okay and they feel great because they think they are getting an added visit tacked onto the stay for the patient, but what they are doing in is running the risk of violating the False Claims act because it actually was not a visit that could be billed.  So if you know you are doing it, stop.  If you do not know, check into it and just make sure that you and your physician are on the same page so that you are not causing yourself any problems with that. 

Now let's talk about well woman exams.  Coding for a non-Medicare patients: if your patient is non-Medicare and you have a well woman exam, you are going to use your preventive medicine visit and of course new or established patients, the 99380 series or the 99390 according to age, and your V72.31.  What I am cautioning you about here is do not code these as problem visits, especially if it is a Medicare patient.  I am going to talk about Medicare billing in a moment, but a lot of doctors when it is a Medicare patient, tend to use the 99214 or the 99213 because they know that Medicare will not pay for the exam.  I think they pay it for every other year.  So they may decide well, I know they do not pay for the well woman exam or I know they are not going to pay for the annual exam so I will just bill it with one of the problems that the patient has had in the past and that is fraud.  The OIG is looking very very hard at this to find those payers that are disguising these visits so I wanted to mention that.  In the meantime on slide 38, if it is a Medicare patient a lot of practices do not know that in addition to billing for the breast pelvic and pap which is your code G0101, you can bill for the collection of the pap specimen.  That is coded with Q0091.  So in Florida for this year you get a walloping $75.39 for your well woman exam, but that is doing it correctly and not gaming the system, so that is the way to do it. 

ABNs are known as advance beneficiary notices and I honestly have found two practices just last month that had never heard of them and they have been a target of the OIG for the past two years.  They are not a target this year, but the point is there have been abuses in how they are used and the OIG is onto this.  Just because this is not a target this year does not mean they will not keep looking at it so want to make sure that anytime you have a Medicare patient and you suspect that Medicare may not pay for it or you know that Medicare will not pay for the service, you will give the patient an advance beneficiary notice which will state what the service is and why you suspect Medicare would not pay.  Then you have them signed it and what this does that is your insurance that you are going to get paid because you are going to tell your payer with the modifier GA on your service and GA tells him that I got the ABN signed by the patient. 

So this affects what the EOB is going to say.  Medicare will send the EOB to the patient and it will say, we do not pay for this but you must pay because you signed the ABN; or they are going to say, if the GA modifier was missing, even though you got it signed, we do not pay for this service and you do not have to pay for it either, strictly because you did not use your GA modifier to tell them.  The truth is, if you did not get it signed, you are going to eat the visit.  The second problem is if you did get it signed, but you did not put it on your claim form, then it is going to be very difficult to get that money out of the patient, they are going to insist that they do not have to pay because this is what Medicare told them on the EOB, so there is going be arguing and they might even want to come in and see where they signed because they do not remember. So, it is good to do that properly and have it in the patient's file.
 
The consultation has been very frustrating for providers.  There has been clarification on what constitutes consultation from a referral.  A consultation is a service rendered to give advice or opinion to a requesting physician about a patient's condition and management.  Whereas a referral is a transfer of responsibility for a patient's care from one physician to another.  Referrals are reported with office visit and hospital visit codes and not consultation codes.  One of the things that is happening here is that physicians are contributing to the confusion because they are using referral, referral, referral for everything that they talk about.  It would be much nicer if they would say, thank you for opportunity to render a consultation on Mrs. So-and-so for the problem, and then render their opinion.  It would make a little clearer, but regardless, there are a lot of problems with this and there is a lot of lost revenue.  And this has been a target of the OIG in the year 2000 then they brought it back in 2002, 2003 and 2004.  It is not a target this year in 2005, but if you read the evaluation and management target, it specifies that certain categories of E&Ms are being abused and they are continuing to watch those.  I am sure that they are talking about consultations without singling them out.  So let us look at this one other way and see if it makes a little clearer to you. 
A consultation has to be at the request of another physician; it is not a referral of a patient to another physician for care and treatment.  A consultation must always include a written report, sent back to the requesting physician and the report must include all findings, opinion of the consulting physician and advised recommendations for treatment of the patient. 

Last but not least, at the conclusion of the consultation, the patient is returning to the requesting physician for continued treatment, and the consultant is not assuming care.  So, that is what makes it real clear for me.  If you refer a patient to someone, you are referring the patient to that doctor because you do not handle that problem and you want that doctor to handle the problem, and that doctor assumes the care of the patient and handles the problem.  And so that doctor will be billing the new patient visit and any surgical procedure he may be taking as well.  Whereas, if you provide the consultation it is totally different, you will use 99241 to 99245.

On slide 42, if you notice the third line, preop clearances are consultations for primary care physicians.  There are so many primary care physicians out there that do not realize that they rendered a consultation.  When the surgical specialist says to the primary care, will you clear this patient for surgery?  He is asking for advice.  Then the primary care physician is going to do the examination and render his opinion in writing, yes or no.  So he has rendered a consultation, so whenever this occurs and you have met the guidelines with the written advice and you received the request, obviously you want to bill for a consultation, because consultations pay a lot more than new patient visits, so we do not want to leave that money lying on the table.  I had stated how important it is to be cognizant of the time spent when providing services earlier.  Now I am going to talk about time in a different aspect.  Our evaluation and management guidelines state that when counseling or coordination of care dominates more than 50% of the patient encounter, then time is the key or controlling factor.  What this means in these cases is, you do not have to arrive at your level of service the standard way by determining history, examination and medical decision-making.  It is strictly based on the amount of time that you spent with the patient. 

So I am going to give you some examples and I hope that you are paying attention, and then you will go back and talk to your physician to make sure that you are not losing money in these instances.  You have a follow-up exam with the patient to discuss a lab or MRI or results of any kind of findings.  There is no examination, you just bring them in to discuss how you are going to tackle this problem.  There is no examination.  You would bill this based on time.  You have got a problem and you are discussing where to go from here.  So, if you spent 15 minutes with the patient, if you look up 99213, the evaluation and management code midlevel for established patients, that is assigned 15 minutes.  A 99214 is assigned 25 minutes, a 99215 is assigned 40 minutes.  Anytime the time can apply to any level of service, it will be written there at the end of the description of that code.  So that is how you can figure out how you arrive at the service - by the amount of time that you spent with the patient.  The key here though is to have the physician get in the habit of documenting how much time he did spend with the patient and then it has to be in the notes, and you have certain ways that you have to document it, which we will go over. 

But here is the second example, look at this one. The patient visits the surgeon to discuss multiple treatment options for breast malignancy.  The physician spent 5 minutes examining the patient and then 20 minutes with the patient and her husband talking about how they were going to proceed with various options they had.  Without time as the key factor this probably would have been a 99212, because in a 99212, the physician typically spends 10 minutes or less with the patient and he only spent 5 minutes with the patient.  In this scenario, though the correct code would have been 99214; we would add the five minutes that he spent on exam and the 20 minutes he spent on counseling for 25 minutes, and since the 20 minutes was more than 50% of the encounter, we can use time.  So we go to 25 minutes and 99214 is the correct code to use.  So this represents a huge loss of revenue for physicians who are not considering and reviewing the time spent with their patients. 

Now, we were discussing earlier the financial loss for undercoding by one level of service or by two levels of service.  If you go back to that slide, the difference between the 99212 and the 99214 was $65.  So this physician , if he billed the 99212 and did not apply time, would have lost $65 for this one visit and that is something we cannot afford to do. 

How do we document this?  We have to provide a concise description of the counseling, any members present for the counseling have to be noted.  We describe any brochures or handouts provided.  The counseling can be described in general terms, but the encounter must have been face to face, and you want to log and document your time and examination time spent counseling.  And what I have all my clients do is include that on the encounter form.  Right after the area where they document the exam, or up where they list the diagnoses for the encounter, just simply put 'time in exam, time spent counseling' with a little line.  Get them into the habit of just it documenting every time, even if it is not going to apply, at least they will be recognizing when it does apply. 

We hit on the global period a little bit earlier.  The global surgical package includes your preop visit, your surgery and your postop visit.  The postop visit can be 10 days or 90 days, for the major surgeries of course it is 90 days.  We have got a couple of issues with regard to the global package and they all present financial losses to our providers.  First of all, the preop visit included in the global is not the visit when the decision for surgery was made.  In those cases, like we talked about earlier, when the decision for surgery is made for the same or next day, we will bill the office visit and we will append modifier-57 and we would not lose that visit, otherwise we will.  We all know that postop visits are coded with a 99024 and that you do not bill, you can document that you had the postop visit, but you do not bill for it, because you cannot charge patient for a visit during the global period.  However, there are times when the patient is seen during the global period for something unrelated to what was provided earlier.  So modifier-24, unrelated evaluation and management service by the same physician during a postop period.  We use this to indicate that an evaluation and management service was performed during a postop period for a reason unrelated to the original procedure. 

So, let us look at some examples on slide 48, the physician excised a benign lesion on the leg.  Six days later, the same patient returns with severe chest congestion and fever.  We would bill the appropriate level of established office visit and append modifier-24 to tell the payer that this patient is in a 10-day global period for the excision of the benign lesion and presented for something totally unrelated to that, so we deserve to be paid for this E&M. 

Another one, I&D of simple abscess was performed on the patient in the office on Tuesday.  Then on Friday, the patient is admitted to the hospital for headache, blurred vision and syncope.  We still are not going to get paid if it is within the global and we do not tell the payer by using modifier-24.  So there is a tremendous amount of money being lost here because there are a lot of offices that have no clue that modifier-24 exists or they just do not bother to track why the patient is coming in, if they are within the global.  So, I would, in your offices, find a way to flag your files of anyone that has got global and the date the global ends, and maybe just three things: they are in the global, the global ends on December 10th and the reason that they are in the global.  That would be a flag for your providers to recognize if they are seeing that patient for something else, to use modifier-24 so you will get paid. 

Modifier-79 is similar.  This is an unrelated procedure or service by the same physician during a postop period.  So now we are looking at a procedure instead of an evaluation and management.  The physician may need to indicate that the performance of the procedure during the postop period was unrelated to the original procedure.  On May 10th, the physician destructed three benign lesions on the truck of the patient and I gave you how you would code that.  And the reason I did this is I am killing two birds with one stone here.  First of all, the first lesion you would bill 17000.  But the next two lesions, you would bill 17003 x2.  A lot of physicians in practices have not taken the time to read the description of this code carefully.  The description for the 2nd through the 14th lesion has a word after it called 'each,' which means that for each lesion you will bill another code.  So it would be, if you had more, it could be 17003 x5.  You do not want to use 17003, thinking it is for the 2nd through the 14th lesion, and that is what happening in a lot of offices.  But to get back on track, we have the same patient returning five days later on May 15th and the physician performed an incision and drainage of a simple abscess on the leg.  This was totally unrelated to what he did five days earlier and he should be paid for that.  How will he get paid for that?  You are going to use your code for this incision and drainage 10060 and you are going to append modifier-79.  Otherwise, if that claim goes to the payer, they are going to have it documented that this patient is in a global period and you are going to be denied your payment.  In some cases, you will need to use both modifiers and you do not want to let this confuse you; you have got the E&M and then you have got the procedures and services.  I give you another example to kind of clarify it on slide 51.  You had a child and you evaluated the child and treated them for a burn on the leg and you did sutures on the forearm.  Six days later, the same child is injured on the bicycle, now he returns with minor bruises, scratches and a chin injury, requiring sutures. 

First of all, you had to evaluate him again to assess his condition and what was necessary to be done, so we will use our 99213 with modifier-24 to show that this evaluation was separate from the prior one.  And then we have the sutures on the chin, so we will bill 12011 with modifier-79, showing that the suture repair was different from the treatment on the leg and the sutures on the forearm, and again you will get paid. 

For slides see pdf of issue.