Medicare and Medical Coding Basics

Reimbursement Concepts

• The presentation is about reimbursement concepts for nursing.
• The speaker is Nancy Munro, RN, MN, ACNP-BC, FAANP.
• The presentation aims to provide an overview of the reimbursement system, review basic billing components, and review critical care billing basics.

History of Reimbursement

• Historically, physician fee-for-service was the primary model.
• The Rural Health Care Protection Act of 1997 was a key legislation.
• The Balanced Budget Act of 1997 enabled nurse practitioners and clinical nurse specialists to bill at 85% of the physician fee schedule.
• Certified nurse-midwives (CNMs) and certified registered nurse anesthetists (CRNAs) have been able to bill at 100% since the 1980s, contingent on clinical circumstances.

Who is Watching?

• Insurance companies
• Centers for Medicare and Medicaid Services (CMS)

Organizations Monitoring Documentation

• State Boards of Nursing
• Pennsylvania Coalition of Nurse Practitioners
• Aetna
• National NP Organizations (e.g., AANP)
• State Carriers (e.g., Novitas Solutions)

Scope of Practice

• Board of Nursing: Legal authorization governing practice
• National: Professional organizations like AANP and AACN regulate practice
• Certification areas, such as adult gerontology acute care nurse practitioners (AG-ACNPs) versus primary care, and adult vs. pediatric acute care are governed by regulations.

APRN Regulatory Model

• Focus of APRN practice extends beyond role and population focus into various healthcare needs (e.g., oncology, geriatrics).
• APRN roles (e.g., nurse anesthetist, nurse midwife, clinical nurse specialist) are often guided by population foci (e.g., family/individual across lifespan, adult-gerontology, neonatal, pediatrics, women's health, psychiatric-mental health).

Why is Coding/Billing Important?

• Comprehensive understanding of coding and billing history is critical for legal, strategic, and economic implications.
• Documentation should rigorously support coding practices.

Reimbursement Structure

• CMS oversees Medical Administrative Contractors (MACs).
• MACs contract with hospital systems.
• A map of CMS MAC regions is available.

Who Can Bill?

• Medicare provider numbers and Medicaid number acquisition procedures are necessary for billing.
• Employment status, listed role, and compliance with regulations like cost reports and Part A are key factors.

Challenge for NPs/PAs/CNSs

• Billing rates for nurse practitioners, physician assistants, and clinical nurse specialists—85% versus 100% of the physician fee schedule—are a key difference.

Medicare Part A

• Inpatient hospital care or skilled nursing facilities are included in part A.
• Critical access hospitals, short-term care facilities, post-institutional home health care, and hospice care fall under this Medicare part.

Medicare Part B

• Physician services and outpatient care are covered.
• Services falling outside of Part A, like physical therapy and diagnostic testing, are covered.
• Enrollment is voluntary.

CMS Website

• Accessing information on CMS website is vital.
• The site provides essential guidance and information regarding various topics, including the Coronavirus Disease 2019 (COVID-19) response.

National Provider Identifier (NPI)

• The NPI is a unique national identifier for all Medicare healthcare services providers
• DEA and other provider numbers may eventually become obsolete due to NPI implementation.
• The implementation finalized in 2008.
• The NPI website is available

If you are interested in billing...

• If interested in billing, essential steps include consultations with physicians, hospital administrators, state resources/experts, and payors.

Reimbursement Terminology

• This section discusses various aspects of reimbursement terminology in healthcare, including but not limited to ICD-10, CPT, RBRVS, and E/M.

Terminology Review

• ICD-10 (International Classification of Diseases) codes classify diseases.
• CPT (Current Procedural Terminology) codes reflect procedures.
• RBRVS (Resource-Based Relative Value Scale) uses RVUs (relative value units).
• E/M (Evaluation and Management) codes encompass patient evaluations and decision-making

ICD-10 Codes

• ICD-10-CM (Clinical Modification) codes are universally used for diagnosis coding.
• ICD-10-PCS (Procedure Coding System) codes are used for procedural coding in inpatient settings.
• The WHO develops and standardizes ICD-10 codes.
• The codes detail the toxic effects of venomous animals, including snake venom, reptile venom, scorpion venom, spider venom, other arthropods, and marine animal venoms.

ICD-10-CM Structure- Format

• The structure of ICD-10-CM codes with digits (e.g., S32 ) corresponds to the category, etiology, anatomic site, and severity.
• The alphanumeric coding incorporates additional characters.

What are CPTs?

• CPT codes represent medical and surgical services.
• The RBRVS scale, effective beginning in 1992, details relative value units for visits and procedures.

RBRVS: Resource-Based Relative Value Scale

• RBRVS influences reimbursement methods.
• RBRVS establishes fees and projections for income.
• RVU describes relative value units for scoring.
• GPCI( geographical practice cost indices) are also used for geographic adjustment factor( GAF).

RBRVS Example: CPT 99213

• Provides examples of calculating reimbursement for CPT 99213 ( generic and new Jersey)

CPT Origin

• CPT codes developed in 1989.
• CMS(Center for Medicare and Medicaid services) relies on AMA/Specialty Society to update the CPT scale.
• The CPT editorial Committee assists with maintaining CPT accuracy and consistency.

Who is Responsible?

• Physicians or non-physician providers are responsible for E/M or visit-based codes.
• Billing providers are responsible for submitted codes.
• The coding process is best driven by an organizational approach involving registration staff members, physicians, nurses, and coding/billing personnel.
• Inaccurate coding may result in revenue reductions and risk of audits/reviews.

Evaluation and Management Categories

• Evaluation and management (E/M) services cover various types of visits (e.g., office or outpatient visits for established or new patients, preventive medicine visits, consultations).
• E/M services describe hospital inpatient or outpatient care, emergency department services, critical care services, neonatal intensive care, nursing facility services, and home services (e.g., domiciliary, rest homes, or custodial).

Basic Principles of Documentation

• Medical records must be complete, legible, dated, signed, bearing the proper credentials, and accurately reflecting all patient encounters using specific methodology/formats for effective documentation.
• Using "rule out" or "possible" wording in documentation is detrimental to proper record-keeping.
• Rationales for tests and diagnoses are also essential to proper documentation.
• Appropriate health risk factors and the patient's response to treatment need clear documentation.
• The use of ICD-10 codes is essential for accurately reflecting the services rendered according to the documented problems to ensure accurate coding practices.

You can't bill for what you do – you can only bill for what you document!!

• Billing is tied to documentation.

Medicare Claims Processing Manual

• Refers specifically to Part 12 (Physicians/Non-Physician Practitioners). The manual provides the framework for proper Medicare claims processing pertaining to physicians and other practitioners.

CMS Documentation Guidelines

• Essential guidelines for E/M services are available on the CMS website.
• Specific dates (e.g., 1995, 1997) for certain documents’ effective periods can be found

Determining the Level of Coding

• The key elements in determining the level of coding include history, examination and medical decision-making.
• Contributing elements in evaluating the level of coding include counseling and coordination of care.
• Non-key elements in coding evaluation do not include time except for critical care/counseling visits

Selection of E&M Service

• Criteria for determining E/M service levels, categories, and subcategories must be carefully evaluated.
• Critical E/M service descriptors at levels 1–5 are also important for coding.
• Determining factors like physical exam, history, and medical decision-making complexity are key.

Physician Fee Schedule (PFS) Changes 2022

• The link provides detailed information about the 2022 physician fee schedule changes.

2022 PFS Changes with Evaluation and Management Rules

• The 2022 changes impacted hospital inpatient and outpatient services, critical care services, and skilled nursing facility and nursing facility services.

Documentation Rules

• This section provides essential information on documenting medical records according to defined rules and guidelines.

The Three Key Components

• History, Examination, and Medical Decision Making (MDM) are essential components in proper medical billing.

"Score Card"

• The score card is developed and utilized by payors, based on CMS rules.
• Medical records are evaluated and scored, based on the presence of key components, namely history, examination, and medical decision-making.

Subsequent Hospital Visit Codes

• Codes are described for subsequent hospital visits; e.g., 99231, 99232, and 99233.

How You Are Going to Document

• Decisions on visit types (clinic, new consult, critical care) should be explicitly documented.
• Consistent consideration of visit intent helps with ensuring proper documentation.
• The level of visit complexity dictates how the service is scored.

History

• The history should contain the history of present illness, past/family/social history and review of systems to describe patient information.

Choosing a CPT Code

• Coding choices must reflect the appropriate visit type (e.g., problem focused, expanded problem focused, detailed, comprehensive).

Chief Complaint

• A concise statement detailing the patient's reason for encounter is crucial.
• Documentation of chief complaints is mandated for all inpatient/outpatient levels of care.
• Ancillary personnel may document the chief complaint, but physician review/approval must follow.
• This component should be clearly stated for follow-up visits.

History of Present Illness

• Details the chronological development of the patient's current illness from prior visits.
• Eight crucial elements (e.g., location, quality, severity, duration, timing, context, modifying factors, associated symptoms) must be documented.

Review of Systems

• A series of questions evaluates body systems for signs/symptoms.
• Two or more positive responses indicate a complete review of systems.
• A complete review will indicate 'all others reviewed negative'.
• There are 14 systems for evaluation.

Past, Family, and Social History

• Consists of the patient's past illnesses, surgical procedures, injuries, current medications, family history (heredity, risk factors), and social history (e.g., tobacco use, alcohol use, living arrangements, marital status, occupation/education).
• This section is crucial for evaluating patient history and risk factors pertaining to all service types.

History Documentation

• History may encompass portions (ROS/PFSH) documented by staff or patient.
• Standardized forms/questionnaires provide necessary detail.
• For inpatients on subsequent visits, the initial H&P (history and physical) note will suffice.

Examination

• Details physical examinations.
• 1995 exam guidelines detail 10 areas (e.g., head, chest) and 12 organ systems (e.g., eyes, cardiovascular)
• Exam documentation should specify abnormal findings and note positive/negative systems details.

Exam Documentation

• "All nl" is insufficient; abnormalities in each body area should be explicitly documented; positive/negative findings must be documented.
• A line through a system does not suffice.
• Documentation should specify pertinent abnormalities on physical examination.

Medical Decision Making

• The amount and complexity of data reviewed, the number of diagnoses or treatment options, and the risk of complications/morbidity/mortality factors are considered for medical decision-making.

Number of Diagnoses & Treatment Options

• Point values based on factors (stable/worsening, new problem, additional work-up) aid in measuring medical decision making.

Complexity of Data

• The minimum, limited, multiple, and extensive criteria help in evaluating data complexity.
• Essential factors for evaluating the complexity of data will include but are not limited to, reviewed labs, x-rays, personal interpretation of tested data from the patient's record pertaining to tests, and reviews/summations of old records.

Risks of Complications, Morbidity, and Mortality

• Establishing a risk level will involve the severity and acute/chronic components of the situation.
• The patient's condition's risks, presenting problem, diagnostic procedures, and management options are important considerations (e.g., minimum, multiple, high, extensive categories).

Yoga Cat

• An image of a cat performing a yoga pose.

Hospital Care (1995) Subsequent Hospital Care

• Subsequent hospital care is described by listing codes 99231, 99232, 99233, and their respective components pertaining to HPI(history of present illness), ROS(review of systems), and P/F/S, medical decision-making requirements, and associated risks.

Shared Visits and "Incident-to" Concepts

• This section describes services provided by multiple clinicians and how they are classified.

Shared Visit Requirements

• Services must be within scope of practice.
• Services should be provided within the same group practice on the same calendar day.
• Physicians/NPs should fully document the visit to support the level of service provided; face-to-face encounters, and billing methods are key considerations.

Shared Visit "Counter-argument"

• Numerical examples supporting billing for shared visits are included.
• An alternative interpretation emphasizing a broader benefit (reducing readmissions, improving patient care) is offered as a rebuttal for the shared visit concept.

2022 PFS Changes

• The practitioner providing the substantial portion of service bills the overall service.
• E/M levels (e.g., history, examination, medical decision making) can determine billing responsibility.
• Time-based criteria are present.
• Modifier (25) is employed for shared/split services.

SCCM Summary of PFS Changes

• Split or shared services are allowed for new/existing patients.
• Billing is based on completion of a component, time required, or provider providing the substantive portion of service.
• A separate identifier for split/shared services is employed; the need to be in the same group is not thoroughly detailed.

"Incident-to" Services

• Describes services incidental to physicians’ services, including services commonly provided in offices and clinics.

"Incident-to"

• The physician must have performed the initial and subsequent services.
• The provider's presence during the service is also required for 100% reimbursement

"Incident-to" Summary

• Criteria for 100% reimbursement are for MD initial and subsequent face-to-face visits; appropriate scope/criteria and fulfillment are necessary.
• Additional 85% reimbursement considerations exist otherwise.

"Incident-to" Update

• MedPAC recommends eliminating incident-to billing for NPs and PAs.
• Existing billing practices obscure Medicare data.
• A separate identifier and enhanced clarification about scope of practice and bill reimbursements are needed.

Critical Care Billing

• Two codes (99291 and 99292) are used for billing critical care.
• Time, the physician's activities, and what is observed are key components for documentation.

Critical Care Billing 2

• Critical care includes instability, clinical decision-making complexity, and time considerations; documentation of these aspects is essential.

Components of CC Billing

• Clinical criterion descriptions (e.g., vital organ system impairment leading to a high likelihood of sudden deterioration) are crucial for critical care billing.

Treatment Criterion (what did you do)

• Critical care requires direct personal management for the patient, assessing, manipulating, and supporting vital organ system functions.

Note Template

• A template for physician documentation in critical care (cardiovascular evaluation components) is provided.

CMS Critical Care Reference

• Essential guidance for critical care services (codes 99291 and 99292) is outlined, with definitions and service specifics.
• The criteria for meeting critical care status (impaired vital organ systems) lead to the need for direct physician involvement.

SCCM Summary of PFS Changes Critical Care

• When medically necessary, follow-up care can be on the same day by physicians or advanced practice providers in the same specialty by aggregating time.
• When medically necessary, critical care can be concurrently provided to the same patient on the same day with more than one clinician.
• Critical care and E/M services may be on the same day.
• Critical care during the procedural period is acceptable.
• Critical care that spans midnight is reported the same day as the visit.

Regulatory Expectations

• Subsequent hospital visit codes compose 80% of bills.
• Critical care codes make up 20% of bills.

CMS Transmittal 1548 (2008)

• If "staff coverage" or "follow-up" by a physician or qualified NPP happens within an hour of initial critical care service, subsequent visits can be coded using CPT critical care add-on code 99292.

Denial Data

• Denial rates for hospital care, emergency departments, and critical care are described using a visual display.
• Denial rates are presented by specialists' versus primary care/NPP categories.

Appeals Process

• Comprehensive information on the Medicare appeals process, including processes and procedures.

Additional Codes and Coding Concepts

• This section discusses additional coding concepts relevant to healthcare billing.

Transitional Care Codes

• Code 99495 (face-to-face visit within 14 days), and code 99496 (face-to-face visit within 7 days) are discussed for transitional care, including examples.

Transitional Care Management (TCM)

• Three components (interactive contact, non-face-to-face services, face-to-face visit) are necessary for 30-day transitional care.
• The link contains comprehensive information on TCM.

Transitional Care Code 99495

• Includes communication (direct contact/electronic); the complexity of medical decision-making during the service period and face-to-face visit within 14 calendar days after discharge are also factors.

Transitional Care Code 99496

• Requires communication, medical decisions with high complexity during the service period, and a face-to-face visit within 7 calendar days of discharge

Dying in America

• The report offers insight into various aspects of palliative care and the challenges encountered when individuals approach end-of-life care and improve quality and honoring individual preferences near end-of-life.

IOM Report "Dying in America"

• The need for healthcare coordination across various settings (medical, social, etc.) and care models is emphasized for quality improvement and end-of-life care.
• Improved methods that address shared decision-making/advance care planning are mentioned to decrease unnecessary medical procedures.

Advanced Care Planning

• CMS manual details pertinent guidelines for advanced care planning, including 99497 (first 30 minutes) and 99498 (each additional 30 minutes) codes.
• There is emphasis on face-to-face explanations/discussions and the appropriateness of using such services.

Advanced Care Planning

• Essential process allowing individuals to plan future healthcare needs.
• Facilitates clear communication and decision-making.
• A separate Part B service covers situations when necessary (medical necessity).
• This service may be included as part of an Annual Wellness Visit (AWV).

Telehealth Services

• Telehealth services are expanding due to the COVID-19 pandemic.
• Originating sites and distant site practitioners are addressed.
• Telehealth services, billing, payment, Place of Service (POS) codes like Telehealth (02) codes are included; the need for clear communication with MACs(medical administrative contractors) is also emphasized.

Medicare Telehealth Services

• Different types of telehealth services include options like in-person visits, virtual check-ins, and e-visits.
• HCPCS/CPT codes are listed for various service types.
• The patient relationship with providers (for new and established patients) are indicated.

Telehealth Services

• Important resources such as Medicare Learning Network guidance and Medicare Claims Processing Manual are outlined.
• Section 190 provides additional information.

Recommendations

• Recognizing billing and coding criteria and understanding their regional payor interpretations and CMS rules are recommended.
• Consulting with compliance departments and state nurse practitioner organizations is also recommended.

Contact

• An email address is provided for contact.

References

• A list of relevant references from various sources is also included to elaborate on the presented concepts.