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Posts Tagged ‘E/M codes’

The RAConteur: The Ministry of Silly Walkbacks

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

Tomorrow marks a birthday of one of my favorite comedy icons. John Cleese, one of the principle members of the legendary Monty Python comedy troupe, turns 71 years old tomorrow. His participation in legendary absurdist comedy sketches such as the Dead Parrot sketch, the fish-slapping dance and especially as the rubber-legged member of the Ministry of Silly Walks, have ensured his place in comic history.

Being a participant in the administrative side of the American health care system, when I think of absurdity, I never have to waste gazes looking at items in the distance. This is particularly true of the RAC process. I have documented in this space the many instances of absurdity that emanate from the RAC side, but in the interest of equal time, it’s time to document a few examples of bloopers coming from the physician practice side. The least surprising preamble that I can add to this is that these issues double as current RAC targets.

New vs. Established Patients – There are provider specialties that are what I like to term “a specialty of NOW”. In other words, I need someone to treat my fracture, that physician treats it now and if I never have another fracture, I won’t see that provider again. In this environment, it is indeed impossible to expect the provider to remember me if it so happens that I have another fracture within three years of my last encounter with that provider. Yet if the provider turns around and bills a new patient visit because he/she doesn’t remember me, I only have one question; what kind of past medical history are you getting from the patient if during the encounter, past orthopedic conditions requiring treatment aren’t discussed or documented? Further, if I pull the documentation of the visit, and the past medical history actually includes a fracture history that affects billing, whose head do I need to smack in order to instill a clue, you or your biller/coder?

NCCI Edits – The National Correct Coding Initiative has been around since 1996. Everyone in a physician office should know about it, the edits that are its foundation are updated quarterly and there are plenty of organizations that offer products that will show you every active edit if you can’t be bothered to look at them on the CMS website. Given these facts, why are you reporting CPT codes on claims with obvious fatal edits? You are a physician, and you should know what procedures are an integral part of the baseline procedure that you are performing. Just because the lysis of adhesions on the 350-pound patient took longer than expected prior to the laparoscopic cholecystectomy doesn’t mean you bill the lysis. Fatal means fatal, as in dead, as in this-is-not-a-H.-P.-Lovecraft-novel-and-the-code-cannot-be-reanimated-and-brought-back-to-life dead. You can stop that now.

Drug Units – You have boxes of injectable drugs in your office. The information that comes with the boxes clearly shows how the drug should be administered, and at what strength. If you’re going to administer it to your patients, there is absolutely no excuse for not knowing how it is billed. Further, the words “unit” and “milligram” are not translated by HCPCS in the way that you think it is. *whispering* - the definition even varies from drug to drug.

These are but just a few issues that I would have thought would have been solved by now. I can talk about complex reviews by RAC contractors demonstrating rank incompetence from now until the current situation is remedied. Automated review is a different arena, and if the same mistakes continue to be committed, not only can I not help you, but thanks to predictive modeling risk scores, I’ll now have to advise you to obtain legal counsel, and to do it quickly.

In other words, you can act absurd by doing a silly walk for everyone to see all you wish, but that behavior leads to a silly walk-back in the form of an easy-to-find monetary recovery, and that is always more painful than attempting to do this with your billing.

A Quick Glance at the Medicare 2010 Physician Fee Schedule

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, J. Paul Spencer, CPC CPC-H

As I stated in a previous posting here, I have a long-standing interest in Russian literature. Developing a love of the novels of Tolstoy and Dostoevsky requires a large amount of free time as well as a hearty concentration level. Yet possessing both of these things does not remove oneself from the fact that War & Peace, owing to its size, works better as a doorstop than most bricks.

Which brings me to the Final Rule for the 2010 Part B Physician Fee Schedule. Weighing in at 1,669 pages, it was a lot to take in. Unfortunately for me, unlike War & Peace, there is no corresponding movie to simplify and edit its contents, yet onward I plunged. Many of the changes were specific to services and specialties, but there were a few things that jumped out at me that I’d like to share with you.

Beginning on January 1, 2010, consultation codes (99241-99245 for office/outpatient, 99251-99255 for inpatient) will no longer be reimbursed by Medicare Part B. In the preamble to this portion of the Final Rule, CMS decided that after many years of attempts at education and clarification of the rules for consultations, there remained mass confusion as to the rules regarding consultation vs. transfer of care, as well as widespread documentation deficiencies and problems with consultation code selection.

To make up for the loss of revenue for consultation codes, There will be a 6% increase in the RVU value on outpatient E/M services (99201-99205 for new patients, 99211-99215 for established patients). Going forward, in the office environment, rather than considering a consultation code for patients referred to their practice from another provider. the physician need only choose an E/M code based on whether the patient has been seen within three years of the service date.

Selecting hospital services in the absence of consultation codes will be a little trickier. CPT codes 99221-99223, which in the past have been used solely by the admitting physician, will now be used by all physicians upon their first encounter with the patient. In order to differentiate from the admitting physician and other physicians providing care to the patient, the admitting provider will be required to add a modifier to his service signifying that he/she is the admitting physician. The modifier to be used was not indicated in the Final Rule, but should reveal itself upon release of the 2010 HCPCS.

One specialty reduction of interest affects chiropractic services (CPT codes 98940-98942). These codes will be subject to a 2% reduction beginning in January.

For advanced imaging services such as nuclear imaging, CMS is now requiring that facilities providing the technical component for these services meet an accreditation standard in order to be reimbursed for these services.  

Of course, the biggest adjustment in the Final Rule is the CMS-projected 21.2% pay cut for physician services. As in past years, this cut is expected to be adjusted by Congress prior to the new year.

In any document almost 1,700 pages thick, there is bound to be information that I have left out. For your reading enjoyment, the Final Rule can be found at the following link: