Optimizing Reimbursement in the Face of Medicare`s
Transcription
Optimizing Reimbursement in the Face of Medicare`s
BUSINESS OF RETINA CODING FOR RETINA Optimizing Reimbursement in the Face of Medicare’s Payment Cuts Changes in the Medicare Fee Schedule mean physicians must adjust their billing practices to optimize reimbursements and prevent audits. BY RIVA LEE ASBELL T he Medicare Physician Fee Schedule (MPFS) payment rates for 2015 alter reimbursement for a number of ophthalmology and retina codes (Table 1). These cuts do not include the potential 21% cut due from the Sustainable Growth Rate (SGR) that is scheduled to take place later this year. If history is any indicator, SGR cuts will be averted, but the MPFS cuts are here to stay. In order to optimize reimbursement, physicians will have make sure their coding and compliance enables generation of all monies that a practice is entitled to and, simultaneously, avoid paying back monies if audited. NEW PATIENTS VERSUS ESTABLISHED PATIENTS Medicare defines a new patient as one who has not received any professional face-to-face service for the previous 3 years. If only a diagnostic test has been performed, and the physician has never seen the patient, then that patient is considered a new patient. The Centers for Medicare and Medicaid Services’ (CMS) contract auditors, such as the Recovery Auditors, audit based on the physician’s NPI (National Provider Identifier) number, and if a physician has examined a patient in any setting during the previous 3 years the patient is considered an established patient. A number of scenarios can occur whereby a patient is considered established. Patients examined from a previous practice are still considered established even though the physician joins a new practice with a different tax ID number. Similarly, if a physician establishes a solo practice 24 RETINA TODAY MARCH 2015 with a new tax ID number, all patients examined in any setting within the previous 3 years are considered established. Another scenario is a patient who sees a physician working part-time for your practice and another practice; that patient is considered established if the physician previously examined the patient at the other practice. As well, patients examined in a hospital as a consultation or as a transfer of care who are subsequently examined in a related office are considered established. Three years goes by very fast, and it is important for whomever is coding to be cognizant that the patient should be coded as new if there has not been a face-to-face encounter for 3 years with the examining physician or in the practice. To prevent audits related to mistakes with erroneously coded patients, I suggest several tactics. Your office should be careful when switching to electronic health record (EHR) systems. Some EHR systems consider any patient entered into the system for the first time to be a new patient. It is important to be sure that established patients are not coded as new patients. The practice will be obliged to refund Medicare the difference between the reimbursement for new patient and established patient at each coding level. Be sure staff and new associates are aware that the NPI is the determining factor in whether a patient is new or not. EHR CODING OF OFFICE VISITS Having audited innumerable EHRs of office visits, I can unequivocally state that there are few, if any, EHR systems BUSINESS OF RETINA CODING FOR RETINA TABLE 1. DIFFERENCES IN MPFS REIMBURSEMENT SCHEDULES BETWEEN 2014 AND 2015a CPT Code Code Description MPFS 2014 Fee MPFS 2015 Fee Percentage Schedule Amountb Schedule Amountb Change (+/-) 67028 Intravitreal injection $113.85 $109.17 -4.1% 67036 PPV $1071.60 $967.17 -9.7% 67039 PPV/focal endolaser $1411.20 $1036.34 -26.5% 67040 PPV/PRP endolaser $1586.08 $1119.34 -29.4% 67041 Vitrectomy with removal of preretinal cellular membrane $1483.39 $1237.17 -16.6% 67042 Vitrectomy with removal of internal limiting membrane $1696.50 $1237.17 -27.1% 67108 Repair of retinal detachment by vitrectomy etc. $1795.97 $1720.59 -4.2% 67113 Complex repair of retinal detachment $1954.26 $1869.50 -4.3% 92012 Office visit, eye code, established patient, intermediate $92.52 $91.30 -1.3% 99204 Office visit, E/M code, new patient, level 4 $176.49 $175.99 -.02% 92235 Fluorescein angiography $117.71 $118.31 +.05% a Reimbursement amounts differ according to area of practice. To find your specific reimbursement rate for 2015, visit your local Medicare Administrative Contractor’s website. b Medicare Physician Fee Schedule (MPFS) amounts for 2015 are those approved by Congress for January 1, 2015 through March 31, 2015. Abbreviations: MPFS, Medicare Physician Fee Schedule; PPV, pars plana vitrectomy; PRP, panretinal photocoagulation; E/M, evaluation and management that accurately code for Medicare encounters, particularly because the chart documentation rarely supports the level of the code selected by the EHR. For example, a template may have the correct number of examination elements to be documented, but the method of documentation is typically not as prescribed by CMS. The final result of all of this is that physicians often undercode from fear of being audited or having to refund monies because the chart documentation does not support the code. Such EHR system inadequacies may be due, in part, to basic programmers’ lack of knowledge about Medicare compliance and guidelines. It is crucial that physicians make an effort to obtain proper coding training for themselves and their staffs. Table 2 offers tips to make sure you stay in the know about guidelines and EHRs. SURGERY ISSUES The most perplexing surgery issues concerning payment involve coding for procedures performed in the global period of another procedure. A patient may present with symptoms unrelated to the medical condition TABLE 2. OPTIMIZATION TIPS • Have your EHR templates professionally critiqued. • Study the 1997 E/M Guidelines. • Free courses (webinars/seminars) are available in various formats from your Medicare Administrative Contractor (MAC). • Be sure to sign up for your MAC’s e-mail lists. Remember, the physician is responsible for adhering to the guidelines and Local Coverage Determinations (LCDs). while still in the global period. However, the surgery may require the same CPT codes that were used in the original Medicare claim. These scenarios usually involve procedures that require the same modality of treatment and, although different, are positioned in the same general anatomic area. For example, if a patient presents with new retinal breaks during the global period of external laser treatment (67145) MARCH 2015 RETINA TODAY 25 BUSINESS OF RETINA CODING FOR RETINA TABLE 3. THE THREE C’S • Clinical Diagnosis • Tip: Be sure to use the symptoms for which the test was ordered if there is no final diagnosis. • Comparative Data • Tip: If it is a new patient, there may not be any comparative data, so just note “Not Applicable.” • Clinical Management • Tip: Describe briefly how the test is being used— this is mandatory for documentation, even if it is a statement such as “No treatment indicated at this time.” for treatment of retinal breaks, then the treatment of the new breaks may be coded for by appending modifier 79, which indicates that the current procedure is unrelated to the original procedure. It is imperative that physicians master the use of modifiers 58, 78, 79, and 59. (See “Coding for Surgical Procedures in the Global Period” in the September 2014 issue of Retina Today for more on this topic.) Choose your surgical codes carefully. For example, when performing a lensectomy in conjunction with a vitrectomy procedure, CPT instructions mandate use of code 66850 (Removal of lens material; phacoemulsification). Using CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy), which is bundled with the vitrectomy codes, will result in that code being denied. Another example is coding for repair of a recurrent retinal detachment in the global period of a previous repair of the retinal detachment using the same technique. In this case, because the second procedure is considered related to the first, the same CPT code (usually 67108 [Repair of retinal detachment with vitrectomy]) plus modifier 78 should be used rather than CPT code 67112 (Repair of retinal detachment by scleral buckling or vitrectomy on patient having previous ipsilateral retinal detachment repairs) plus modifier 78 . Both are correct, but using the code 67108 with modifier 78 results in higher reimbursement. Peripheral iridectomy (66625) is not bundled with the retinal detachment repair codes and may be coded if medically necessary. In order to prevent audits and subsequent paybacks, do not use modifier 25 to engender payment for an office visit when coding intravitreal injections or other surgeries classified as minor (zero day global period for Medicare) unless there is a separate and significant condition that is being addressed. 26 RETINA TODAY MARCH 2015 Also, you should avoid excessive use of modifier 59, especially for treating the same condition by the same modality in contiguous structures. The National Correct Coding Initiative (NCCI) specifically states that “two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries. … The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. … Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site.” Be sure you and your billing staff are up-to-date on Medicare’s latest modifier 59 regulations. (See “New Modifier 59 Coding Revisions” in the November/December 2014 issue of Retina Today for more on this topic.) OPHTHALMIC DIAGNOSTIC TEST ISSUES Retina practices tend to use diagnostic testing more frequently than most other ophthalmic subspecialties. For instance, the utilization rate of extended ophthalmoscopy by a retina specialist per 100 beneficiaries is likely to be significantly higher than that of colleagues in cataract and refractive surgery or glaucoma practice—a fact that is likely to trigger a utilization audit. CPT 2015 requires a written interpretation and report for all diagnostic ophthalmic tests except for gonioscopy and ophthalmodynamometry. The report should include the Three C’s found in Table 3. It is imperative to document the interpretation and report separately from the main body of the chart documentation and to ensure it is properly labeled. (See “Chart Documentation for Ophthalmic Diagnostic Tests” in the May/June 2014 issue of Retina Today for more on this topic.) To avoid audits, make sure the chart documentation contains an order for each test and a signature. Also, make sure that images of any diagnostic tests, as well as an interpretation and report, are included for each test. For example, if you intend to bill fundus photographs and fluorescein angiography separately in order to receive separate payment for each, then each test requires an individual report. n Riva Lee Asbell is the principal of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm located in Fort Lauderdale, Florida. Ms. Asbell may be reached at [email protected]. CPT codes copyrighted 2014 American Medical Association.