CODING, A TOUGH ACT IN ANY ENVIRONMENT

By Emilie J DiChristina, MBA for PracticeFirst

Over the last several weeks I have had the opportunity to work with medical records in the capacity of:

  • Clinical coding auditing;
  • Clinical Documentation Improvement; and
  • Coder

From the experiences above, you may be expecting a rant about “those darn providers”, or “cutting and pasting in EMRs” and so forth, and in truth, all of those comments may be valid for those involved in coding at any time. The issue that has struck me the most regarding coding over the last several weeks is the potential for variance among coders, among providers, among revenue cycle managers when it comes to the codes themselves.

A simple would be the coding for a patient getting a vaccine. Some coders include a “nurse visit or 99211”, some include a low level provider visit, while others code just the vaccine. In large part this is practice preference, however when coders go from one provider to another, these variances may be set-in.

Another example are those coders who are clinically trained as they really dig into the chart for specifics to diagnoses, or even worse – read into the record “what they think the provider is trying to say”. I’m as guilty of this as anyone.

It is safe to say that coding variances are more the rule than the exception.

In 2008 at the Perspectives in Health Information Management, Computer Assisted Coding Conference Proceedings; M. Elliott Familant, PhD, et al discussed the need for a Gold Standard in medical coding. Their specific comments on coding variability are as follows:

“Multiple studies have shown that medical coders will frequently differ in the number and type of codes they apply to medical charts. This is true for ICD-9-CM and ICD-10 coding  and CPT (Current Procedural Terminology) codes, including E&M coding.  Coder variability is a significant challenge in developing any standard of “correctness” for medical coding.”

Also, in the AAFP publication, Fam Pract Manag. 2005 Jun, Cindy Hughes CPC and Trevor Stone discussed similar concerns. In their article, they note:

“Coding is more an art of interpretation than an exact science. Nowhere is this truer than with E/M services. In 2000, the Journal of Family Practice published a study in which four faculty physicians, six resident physicians and six professional coders audited 1,069 charts.1 The results indicated that professional coders agreed with the codes assigned by the physicians far more often than did the physician or resident auditors. Further, when auditors disagreed with a code selection, the documentation justified a higher level of service four times more often than it suggested a lower level of service.

Another recent study involving a review of E/M codes assigned to 125 visits by pediatricians found that 44 percent of the visits were undercoded and 1 percent were overcoded.2 Before correction of the undercoding and overcoding, the code distribution showed a bell curve with the predominance of claims at the midlevel (99213). After correction based on the proportion of error found by the independent review, a more equal distribution of midlevel (99213) and upper level (99214) codes was demonstrated.

In a third study, 600 family physicians were sent surveys asking them to assign codes for six different clinical scenarios.3 The 205 physician responses agreed with expert CPT E/M code assignment in 52 percent of the scenarios for established patient visits. Undercoding was the most common error, identified in 33 percent of the cases. Again, the bell curve showed a more equal distribution of codes 99213 and 99214 after correct coding was applied.

Yet another study found that family physicians undercode their services at least as often as they overcode (22 percent undercoded, and 20 percent overcoded).

These studies indicate that coding of E/M services is not a clear-cut process. Physicians have difficulty choosing correct codes for these services based on the guidelines available, and even trained coders often disagree.”

So what does that mean for coders, auditors, revenue and compliance staff, and the providers overall? It means there needs to be clear cut practices, internal auditing, and a coding staff which knows your specialty, and gets routine feedback from a lead coder or coding manager.

It is impossible to eliminate every variance and there is an understanding that coding, particularly in the area of E&M may have a +/- swing of 1 code (which in some cases in considered unavoidable, but still undesirable), however the use of only highly trained, educable coders, well versed in your specific specialty is a goo

PRACTICEFIRST’S CODING CORNER – FEBRUARY 2013

By Lisa Kropp, PracticeFirst Coding and Credentialing Manager

MEDICARE EHR INCENTIVE PROGRAM- MEANINGFUL USE

Q:        What is Meaningful Use?

A:        CMS has established objectives that all providers must meet in order to show that they are using their EHRs in ways that can positively affect the care of their patients—in other words, so that providers can demonstrate meaningful use.  It’s not enough just to own a certified EHR. Providers have to show CMS that they are using their EHRs in ways that can positively affect the care of their patients.

Q:        What do I have to do to show I am “meaningfully using” my EHR?

A:        Providers must meet all of the Stage 1 requirements that CMS has established.

Q:        What’s a reporting period?

A:        Note: For the first year you participate, you have to meet the requirements for and report data on a continuous 90-day period during the calendar year (any 90 days from January 1st to December 31st).

For the remaining years they participate, eligible professionals have to meet the requirements for the entire calendar year.

Q:        How can a certified EHR help me?

A:        All certified EHR technology adheres to the standards and criteria of the EHR Incentive Program—which means it is certified to include functionality that will help you accomplish the core and menu objectives you must meet.  In addition, Certified EHR technology includes the ability to calculate the numerators and denominators for all of the objectives based on the patient information you enter as part of your everyday workflow.

Q:        What are the “measures” an Eligible Professional has to meet in order to receive payment?

A:        #1:       15 CORE OBJECTIVES—These are objectives that everyone who participates in the program must meet. Some of the core objectives have exclusions that could exempt you from having to meet them, but many of them do not. You have to report on all 15 core objectives and meet the thresholds established by those objectives.

#2:       5 of 10 MENU OBJECTIVES—You only have to report on 5 out of the 10 available menu objectives. You can choose objectives that make sense for your workflow or practice. Again, some of these objectives have exclusions that could exempt you from having to meet them.

#3:       REPORT ON CLINICAL QUALITY MEASURES—6 Total (3 Core or alternate core and 3 out of 38 from the Menu Set).Measures and Clinical quality measures do not have thresholds that you have to meet—you simply have to report data on them.  You don’t have to do any calculations for the clinical quality measures! Your certified EHR will produce a report with clinical quality measure data, and you must enter that data exactly as your certified EHR produced it.

Q:        Where do I go for more information on the Core Objectives, Menu Objectives and Clinical Quality Measures?

A:        www.cms.gov/EHRIncentivePrograms

Q:       What is attestation?

A:       Attestation is a legal statement that you have met the thresholds and all of the requirements of the Medicare EHR Incentive Program.

Q:       Where can I go for instructions on how to attest?

A:       https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/EP_Attestation_User_Guide.pdf

 Note: February 28, 2013 is the last day for Medicare eligible professionals (EPs) to register and attest to receive an incentive payment for calendar year (CY) 201

BILLING UPDATES FEBRUARY 2013

By Karin Bajak, PracticeFirst Billing Manager

IRS INSURANCE COMPANY PAYMENT SUMMARY

PF will aggregate your IRS Form 1099’s through February 15th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2011.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance payers should mail them by January 31st.  However, our past experience indicates that they do not comply by the due date and therefore they are not all received until the third week in February.  At that time, we will send them to you by mail or through our courier service.

CENTERS FOR MEDICARE AND MEDICAID (CMS)

HEALTH PROFESSIONAL SHORTAGE AREAS (HPSA) UPDATES FOR 2013

Significant changes to the HPSA designations have taken place effective for January 1, 2013 services dates. The major changes impacting our clients are for those physicians who render services in Batavia and Warsaw. These two areas are no longer eligible for the primary care HPSA incentive, but still qualify for the mental health HPSA incentive. Information regarding HPSA physician bonuses is located:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses

MEDICATION CERTIFICATION STATEMENTS

On a yearly basis, Medicaid requires a signed recertification statement in order for Practicefirst to submit provider’s Medicaid claims electronically. Medicaid also requires this certification to allow us to check claim status electronically. These certification statements require your signature be notarized. You may take advantage of our notary service by stopping in our office to see Becky Amann. She can be reached at (716) 348-3902. Otherwise you will need to obtain the notarization elsewhere before returning the form to our office.

CENTERS FOR MEDICARE AND MEDICAID (CMS)

HEALTH PROFESSIONAL SHORTAGE AREAS (HPSA) UPDATES FOR 2013

Significant changes to the HPSA designations have taken place effective for January 1, 2013 services dates. The major changes impacting our clients are for those physicians who render services in Batavia and Warsaw. These two areas are no longer eligible for the primary care HPSA incentive, but still qualify for the mental health HPSA incentive. Information regarding HPSA physician bonuses is located:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses

MEDICARE PAYMENT CUT AVERTED

On Wednesday, January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012. This new law prevented the scheduled Medicare payment cut for physicians. It also reflects a zero percent update for physician services through December 31, 2013.

National Government Services (NGS) released the 2013 physician fee schedule on January 15, 2013.  Medicare claims containing 2013 dates of service were held until the fee schedule was in place. NGS anticipates that the hold will have a minimal impact on physicians’ cash flow, since claims are always held for 14 days before payment is issued.

NATIONAL DRUG CODE (NDC)

Medicaid as well as all Medicaid Managed Care and Family Health Plus plans require providers to report the NDC on claims when billing for physician administered drugs. If the NDC is not reported, claims will deny. As mentioned in previous client memos, the NDC information can be obtained from the drug invoice or packaging information. Furthermore, Medicaid requires the quantity and unit of measure for physician administered drugs. Please provide us with this information when forwarding the charge slip to our office for billing. A copy of the drug invoice must be attached to the charge slip as well, in order for PF to bill these types of claims correctly. If we do not receive this information from our clients, the charge slip will be returned to you as a Chart Return requesting this information.

UNIVERA NEWS

IMPORTANT NOTICE REGARDING REIMBURSEMENT UPDATES EFECTIVE APRIL 1, 2013

Effective for dates of service on or after April 1, 2013, Univera Healthcare will update its reimbursement rates for:

  • Commercial Lines of Business (Traditional indemnity, HMO, PPO, EPO, Point of Service). Univera is pleased to let you know that they have allocated an increased level of reimbursement to Evaluation and Management codes.
  • Medicare Advantage  (Medicare HMO & PPO)
  • Special Programs (Transitions and Healthy NY B)<