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Welcome to PMI’sWebinar PresentationBrought to you by:Practice Management Institute pmiMD.comMeet the Presenter On the topic:Billing ComplianceversusCoding ComplianceJeffery RestuccioCPC, COCRitecode
Welcome to Practice Management Institute’s Webinar and AudioConference Training. We hope that the information contained herein willgive you valuable tips that you can use to improve your skills andperformance on the job. Each year, more than 40,000 physicians and officestaff are trained by Practice Management Institute. For 30 years, physicianshave relied on PMI to provide up-to-date coding, reimbursement,compliance and office management training. Instructor-led classes arepresented in 400 of the nation’s leading hospitals, healthcare systems,colleges and medical societies.PMI provides a number of other training resources for your practice,including national conferences for medical office professionals, self-pacedcertification preparatory courses, online training, educational audiodownloads, and practice reference materials. For more information, visitPMI’s web site at www.pmiMD.comPlease be advised that all information in this program is provided forinformational purposes only. While PMI makes all reasonable efforts toverify the credentials of instructors and the information provided, it is notintended to serve as legal advice. The opinions expressed are those of theindividual presenter and do not necessarily reflect the viewpoint of PracticeManagement Institute. The information provided is general in nature.Depending on the particular facts at issue, it may or may not apply to yoursituation. Participants requiring specific guidance should contact their legalcounsel.CPT is a registered trademark of the American Medical Association.Practice Management Institute 8242 Vicar San Antonio, Texas 78218-1566tel: 1-800-259-5562 fax: (210) 691-8972info@pmimd.com
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Billing ComplianceversusCoding ComplianceJeffrey Restuccio, CPC, COC, MBAMemphis TN(901) 517-1705jeff@Ritecode.comwww.Ritecode.comRanking of Guidelines (CPT Concepts)State RegulationsState BoardsMedicaid GuidelinesMedicare AdvantagePrivate Payor GuidelinesMedicare GuidelinesGeneral CPT Concepts – AMA GuidelinesIf Medicare guidelines disagree with AMA CPT guidelines who do you go with?2Ritecode.com1
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Billing Compliance vs Coding ComplianceThe question is: Who’s compliance?Who can audit you? MedicaidMedicarePrivate carriersOIG/RACBoard (cardiology, orthopedic, ophthalmology)3Ritecode.comWhat is a pure coder? Modifier E1, E2, E3, E4 versus RT and LT.Modifier 51 (surgical)Modifier 25Reading surgical Op Reports for additional services.Telling the “complete story” of the encounter.Reporting medical misadventures.4Ritecode.com2
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Know Coding and Billing Basics Have a current CPT manual or LCD.Have a current ICD-10 manual or access.Have a copy of the AHA ICD-10 Guidelines for2016.Have a current HCPCS book.Know your bilateral indicator codes.Know your global days (zero, 10, 90).Know modifier rules.Know ICD-10/CPT linking or medical necessityrules.5Ritecode.comCoding Compliance Flowchart Discussing and reviewing this document, alonecould take a full hour – with your interdepartmentalteam.1.2.3.4.5.6.Compliance Team – Quarterly Meetings.Determine the reports you want generatedAudit ReviewsCorrective Procedures/TrainingCompliance elementsCoding Resources6Ritecode.com3
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 20167Ritecode.comSpecific Coding ComplianceExamples Misuse of the 2 of 3 rule.Misuse of modifier-25UpcodingDowncodingCloningMixing the right and left side due to cloning of surgicaloperative notes. (Yes I have seen this during audits.)8Ritecode.com4
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Compliance Plan Implementation Regardless of whether its for coding or billing, every clinicshould conduct at least one compliance plan meeting.Bi-annual, quarterly, and monthly meetings as needed.Everyone on the team should have action items, targets anddue dates.This is a marathon, not a race – it’s easy to get discouraged.Also get ready for pushback from the doctors, finance, codersor billing.There will be many obstacles to implementing both codingand billing compliance.9Ritecode.comComponents of BillingCompliance RVU’s and the Medicare allowable amountRefundsSubmitting claims within the allowable period.Financial policy and Advance beneficiary notices (ABN)ABN goes in the medical record.ABN is signed by patient; -GA modifier is appended tothe code.Utilization review.New technology and equipment purchase.Provider education; niche markets.10Ritecode.com5
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Some suggestions Have the coding manager and the billing create separatecompliance or issue documents.Make a specific list of areas where they could or are inconflict.Create a policy and guidelines for resolving conflictsbetween billing and coding.Get buy-in from the most supportive provider and usethat provider to help convince the others.11Ritecode.comUnique conflicts (true stories) One of the founding five partners had almost zero percentaccuracy and compliance in the audit. The documentationwas virtually non-existent. Technically, based on a codingcompliance plan, this provider should have been first verballyreprimanded, then reprimanded in written format, not allowedto bill, and potentially fired. Of course that would neverhappen. How do you handle this situation? Working with a large multi-specialty group I needed thesupport of the clinic medical director. After reviewing hisrecords and talking with him, I realized that he was the leastqualified of his doctors in terms of documentation andcompliance.12Ritecode.com6
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016More Stories New technology, service, or HCPC code (supply) is marketedto the clinic as a “potential to increase revenue.”Billing, coding and the clinical director must be involved.Is there a CPT or HCPC code for this product/service?Is it accepted by any carrier and is it documented?Don’t take the sales representative’s word for it.You may find conflicting information on reporting it.If you are not sure, simply ask the carrier.Although rare, it is possible to get an unlisted code paid.Also more rare but have seen a category III code paid.13Ritecode.comData Entry “busy work” Coders creating extra work for billing/data entry.Billers not understanding why a claim is denied.A pure coder not understanding carrier-specific rules.Additional ICD-10 codes that tell the story but don’timpact reimbursement.Modifiers that may be no longer necessary or requiredby many carriers (MOD-51, MOD-52, MOD 32).Just because a coder is certified it does not mean theycan audit or know anything about the real world.14Ritecode.com7
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Documentation and Billing Before you can maximize revenue you must ensureoptimal compliance and therefore accurate and completedocumentation.This is very important because often they are notconducted simultaneously.If you are compliant you can always code at the highestdocumented and accurate level.The billing department should instigate documentationaudits because without accurate and completedocumentation you will owe money if your audit does notmeet guidelines.15Ritecode.comDocumentation Audits HistoryExam elementsMedical Decision MakingInterpretation and ReportSurgical Operative ReportsSpecialty reviews of all Local Coverage DeterminationsWhat about Weighted Average Reviews ? Is it a coding orbilling request? In one clinic all utilization statistics werecreated from the finance department, not the codingdepartment.16Ritecode.com8
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Billing Compliance and Revenue With our new service/coder/CEO we are getting paid foreverything and revenue is up. Everyone is getting abonus.Someone in your organization should be concerned ifrevenue increases suddenly.New procedures are being billed.Are there coding compliance policies in place?Utilization review?Coding Compliance planBilling Compliance plan?17Ritecode.comCarrier Tips and Tricks When calling your carrier always get the person’s nameand email address if possible.Chat them up and compliment them on how hard theywork. Be nice even if you are frustrated with them.When you ask them what modifier to use they will say,“we cannot tell you how to code.”Always work to get a carrier representative for your topcarriers (Medicare, Medicaid, Blue Cross).Always get any unique instructions in writing. Ask fortheir E-mail address and send them an overview of thediscussion and have them reply.18Ritecode.com9
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Have you read your contractlately? Occasionally there will be surprises there: A Blue Cross Blue shield contract not allowing you to billthe patient if you do not meet timely filing.A BC/BS policy not allowing the clinic to bill other patientsa lower fee (like Medicare).If you are a large clinic you may be able to negotiateeither higher reimbursement or reimbursement forunlisted codes or even category III T codes. (Not easybut it has been done.)19Ritecode.comMedicare Guidelines Well over 1400 pages.Very detailed payment and documentation guidelines.Over 74% of private carriers follow Medicare guidelines.Many guidelines are local and not national.Medicare and the OIG will audit you.Never pays for refraction or glasses.Medicare Concepts: “Incident To” ServicesLocal Coverage Determinations1997 Exam Guidelines20Ritecode.com10
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Medicare Jurisdictions Medicare is not one monolithic agency.There are multiple contracts and jurisdictions.Each Medicare contractor can have slightly differentrules. I call these carrier-specific rules.Most are very similar–but the exceptions are what willtrip you up.Many of you have had your Medicare carrier changeover the last ten years.21Ritecode.comMedicare is moving from 16 to 10jurisdictions (Medicare Providers)JN6KEFHLM1558CahabaFirst CoastNGSNGSNoridianNoridianNovitas SolutionsNovitas SolutionsPalmetto GBA (J11)CGSWPSWPS22Ritecode.com11
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Medicare Jurisdictions23Ritecode.comLocal Coverage Determinations(LCDs) For some procedures there are national coveragedeterminations. (NCD)LCD’s are published by your local Medicare provider.Go to the Medicare website; find Provider information,find LCD’s or publications; review the long list of LCD’sand find all that pertain to your specialty.If your carrier does not have an LCD find another onefrom another Medicare carrier (a different state).There are Active, Retired, and Draft LCD’s.24Ritecode.com12
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016What is Medicare Advantage (MA)? MA (aka Medicare Part-C) is required to offer at least thesame amount of coverage as Medicare Part-B, but caninclude other benefits, like routine vision, dental, andhearing coverage.Some Medicare Advantage plans include full coveragefor routine vision exams, vision correction products, andother vision care. This will be by plan and vendor.25Ritecode.comWhat is Medicare Advantage (MA)? MA is not as simple as Part-A or Part-B.1. Each MA plan can be further divided into different plan types[next slide]2. While most will follow Medicare Part-B guidelines for your state(local vendor) some offer services not covered by MedicarePart-B.3. While most MA plans will defer to the local Medicare Part-Bcarrier some MA plans have their own Coverage PolicyBulletins. Is everyone with me?26Ritecode.com13
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Medicare Advantage Plan Types MA plans provide the patient with all their Part A andPart B benefits. Medicare Advantage Plans include:1.2.3.4.5.6.Health Maintenance Organizations (HMO).Preferred Provider Organizations (PPO).Private Fee-for-Service Plans (PFFS)Special Needs Plans (SNP)Medicare Medical Savings Account Plans (MSA).HMO Point of Service (HMOPOS) Plans (rare): An HMO Planthat may allow you to get some services out-of-network for ahigher cost.27Ritecode.comAdvance Beneficiary Notice(ABN) Required by Medicare if you want to bill the patient for anon-covered service (does not meet medical necessity).Have the patient fill out the form. Explain that you maybe paid, but if not they are responsible.Append modifier GA to the code.Use on screenings without medical necessityBe sure you have the latest version. Download from theMedicare website.28Ritecode.com14
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Medicare PFSRVU database Physician Fee Service and Relative Value Unitdatabase. An ASCII/excel file on the Medicare website. Itis free to download.Includes: Bilateral surgery indicator (modifier)Global DaysBreakable or not breakable NCCI edit flag.Professional and Technical ComponentRVU dataMuch more.29Ritecode.comBilateral surgery indicator 1 Unilateral2 Bilateral9 Concept does not apply3 150 % rule does not applyThese flags are in the Medicare PFSRVU database.Some call them the bilateral surgery modifier.Some diagnostic codes are inherently bilateral such asfundus photography and visual field exams.Not in the CPT manual.30Ritecode.com15
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Global Period Also called Global Fee or Global Days. This applies tosurgical procedures.Zero days; 10 days; 90 days; YYYY (contractor-priced); ZZZZ(add-on codes)Not applicable to diagnostic specialty tests (audiology,eyecare, psychological).Co-managementThe change to the global period codes is now on hold ads/GloballSurgeryICN907166.pdf31Ritecode.comSmall surgical procedures Foreign body removalBiopsiesEar lavageEpilation (removal of an ingrown eyelash): 67820 (forceps)modifiers E1-E4, or RT or LT.10-day global or zero day.How would not understanding global days impactreimbursement?Need adequate documentation.Should always be “separately identifiable” if reported with anE &M32Ritecode.com16
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016National Correct Coding Initiative (NCCI) Edits Not in the CPT manual and not in the PFSRVU database.This information is separate.Medicare has files you can download (excel, ASCII)Long lists of CPT codes that cannot be reported on thesame DOS.Breakable editsUnbreakable editsUse Mod-59 to break an edit. This is for two procedures onthe same DOS. 2nd procedure must be separatelyidentifiable.Usually included in edit software and specialty manuals.33Ritecode.comSpecialty Coding Manuals OptumDecision HealthPMICCoding InstituteUnderstand that they split the difference between localcoverage determinations and national. In other words,they cannot accommodate carrier-specific rules. It is aninherent problem with national coding advice.34Ritecode.com17
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Relative Value Units (RVU’s) Relative Value UnitAll reimbursable procedures/services have an RVU value.E & M codes, surgical procedures, diagnostics, labs,radiology.Small procedures have low RVULarge procedures have high RVU’sDetermines your reimbursement.Ritecode Coding Advisor has RVU’sCoding specialty manualsList CPT codes in decreasing RVU value.Not in the CPT manual.35Ritecode.comInterpreting RVUs CY 2016 Physician Fee Schedule database.Medicare pays different fees in each of 92 localities orGeographic Practice Cost Indices (GPCIs) across theU.S.The split of RVUs varies by physician service but as ageneral guideline (on average):Work RVUs52.5 percentPractice Expense (PE)43.6 percentMalpractice Insurance RVUs3.9 percent36Ritecode.com18
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016RVU ExamplesCalculatedRVU 69210Cataract surg w/iol 1 stageNasal/sinus endoscopy dxOffice/outpatient visit estRemoval of skin tagsDrain/injection joint/bursaRemove impacted ear ic Practice Cost Indices(GPCIs) The Geographic Practice Cost Indices (GPCIs) reflectthe relative costs associated with physician work,practice, and professional liability insurance in aMedicare locality compared to the national averagerelative costs. There are three, individual GPCS values: Cost of Living GPCI: Applied to physician work relativevaluesPractice Cost GPCI: Applied to practice expense relativevaluesProfessional Liability Insurance Cost GPCI: Applied toprofessional liability insurance relative values.Ritecode.com3819
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016GPCI ExamplesLocality 2016 GPCI IndexWorkPEPMILos Angeles, CA1.036 1.154 0.642Northern NJ1.044 1.186 1.045West Virginia0.963 0.828 1.229Tennessee0.972 0.898 0.523Houston, TX1.009 1.002 0.923Ritecode.com39Setting Fees for Services Physician compensation level for a particular service(think CPT code ) is composed of three components:1. A Relative Value Unit (RVU) assigned to it. (Total ofWork, PE and PLI).2. A geographical adjustment (GPCI) for you state orcity is applied to each of the three RVU components.3. Multiply by the current year Medicare conversionfactor (CF).Ritecode.com4020
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Fee Considerations Some Clinics set their fees at 130% or 150% or even200% of the Medicare allowable.Higher fees will mean higher contractual write-offs peryour private carrier contracts.Many private carriers will have a fee schedule.High fees could be an issue if you have a lot of Self-Paypatients.Always review your top 25 carriers payments every yearon your top 25 services (do a search in your practicemanagement system for your top 25 CPT codes)Ritecode.com41Fee Setting Strategies Be consistent – do not have two fee schedules ordifferent price structures.No carrier will pay more than what you charge even iftheir fee schedule is higher. Some carriers reimbursehigher on services than others. Do you know who theyare?Remember that patients get a copy of the EOB and cancompare what you charge versus what the Plan pays.Ritecode.com4221
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Fees – Other Considerations Some Plans/Carrier pay a percentage of your billablecharges. This can happen when a patient is “Out ofNetwork.” Therefore higher charges are best in thisscenario.Specialties tend to bill higher charges, as a percent ofMedicare – but again there is no one formula.Do not charge any non-Medicare patients less than whatyou charge Medicare patients.Always read your contracts for “fine print” concerningbilling.Ritecode.com43Medicare Conversion Factor Total RVU’s are multiplied by the conversion factor toprovide the Medicare allowable amount. MPFS (Medicare Physician Fee Schedule) 2013: 34.022014: 35.82282015: 35.8013 2016: 35.8043 Ritecode.com4422
Practice Management Institutewww.pmiMD.comWebinar/Audio ConferenceAugust 4, 2016Other RVU Facts The RBRVS is not used to pay for anesthesia services.Medicare uses a separ
Know Coding and Billing Basics Have a current CPT manual or LCD. Have a current ICD-10 manual or access. Have a copy of the AHA ICD-10 Guidelines for 2016. Have a current HCPCS book. Know your bilateral indicator codes. Know your global days (zero, 10, 90). Know modifier rules. Know ICD-
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