Renee Stantz

Renee StantzQ: Our office is starting to do a monthly audit of our physician charts. We’re going to be looking at documentation and coding to make sure they are on the right track. When we’re conducting these audits, do we have to use either 1995 or 1997 guidelines or can we combine the two?

	A: Historically, the Center for Medicare and Medicaid Services (CMS) has instructed that one of the Evaluation and Management (E/M) Guidelines had to be used-either 1995 or 1997-when charts were reviewed, internally or externally. 

	Recently, however, they have changed (and I believe advanced) their instruction to state that, “… beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness (HPI) along with other elements from the 1995 guidelines to document an evaluation and management service.” 

	The full article, “Medicare E/M FAQs,” can be found at: 

	Let’s discuss what this means exactly and how it will benefit your physicians and non-physician practitioners (NPPs) in their reviews.

	First, let’s review the differences and similarities between the two guidelines.

	There are not too many differences between the 1995 and the 1997 guidelines and there are some similarities. Let’s discuss both of the guidelines now. 

	Two major differences exist between the 1995 and 1997 E/M guidelines:  HPI and the exam element. 

	The following criteria are the same for the 1995 and 1997 E/M guidelines, including: The Review of Systems; Past, Family and Social History; and Medical Decision Making.

	Now, let’s delve into the two major differences: HPI and the exam.

	The HPI is arguably one of the most important pieces of E/M visit documentation because it, in conjunction with the chief complaint, supports medical necessity for the visit.  It is described in the Current Procedural Terminology (CPT) guidelines as “a chronological description of the development of the patient’s illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

	For an extended HPI, the 1997 E/M Guidelines also allow for “the status of at least three chronic or inactive conditions.”

	Until September 10, 2013, CMS had strictly interpreted the guidelines and only allowed the status of at least three chronic or inactive conditions when utilizing the 1997 E/M Guidelines.  However, physicians/NPPs and reviewers now can “mix” the guidelines in so far as credit can be given in the HPI for the elements listed above or the status of three chronic or inactive conditions regardless of which set of guidelines being utilized.

	For years, reviewers have thought that credit should be given to physicians/NPPs for the status of chronic conditions for either set of guidelines. This is because it takes the provider’s time and medical knowledge to review the patient’s chronic conditions, and this type of thoroughness is simply good patient care. 

	The guidelines state that reviews should be conducted so that the physician/NPP obtains the most favorable outcome, and allowing for the review and status of chronic conditions in the HPI further advances this goal.

	While most of the guidelines remain the same between the two versions, the exam component is very different. The 1995 guidelines include a one-size-fits-all multi-system exam that recognizes body areas and organ systems.

	In contrast, the 1997 guidelines not only offer a general multi-system exam, but also single organ system examinations for:

	Without question, the 1995 guidelines are much more straight forward and are easier to use for physicians/NPPs and reviewers alike.

	 However, specialty physicians and NPPs sometimes find that single organ system exams are better suited to document their specific specialty elements, while general practitioners tend to lean toward the 1995 general multi-system exam because they don’t normally need the specificity that the single organ system exams offer. Physicians/NPPs and reviewers can-and should-choose the examination that most benefits the physician or NPP. 

The answer to our reader’s question was provided by Renee Stantz, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your practice management questions to 

Articles

Our office is starting to do a monthly audit of our physician charts. We’re going to be looking at documentation and coding to make sure they are on the right track. When we’re conducting these audits, do we have to use either 1995 or 1997 guidelines or can we combine the two?

Physician documentation audits: Can 1995 and 1997 E/M Guidelines be combined?

	So you’ve decided to get your practice ready to use ICD-10-CM coding. Where do you begin? Our experts recommend the following steps:

	“Appoint one person, be it the officer manager, the coder, or the biller, to drive the process and oversee all the details,” says Maxine Lewis, presidentof Medical Coding and Reimbursement.   

	“I think it’s important to put goals in front of yourself to achieve this planning,” she says. 

Identify your codes and assess coder knowledge:

	One of the most important elements in preparing will be identifying the codes your practice uses the most, so that you can begin learning what they will be in ICD-10-CM, Lewis says. The easiest way to do this is to review your superbills. Also, you must make sure your coding staff has knowledge in the areas of basic anatomy, physiology, and medical terminology. This will be necessary for them to better understand the provider’s documentation.

Analyze your contracts with third-party payers:

	“Chances are, you have a lot of services that are carved out, or services that are automatically provided because of a certain diagnosis. So you have to find those in your contracts and make sure you’re using ICD-10-CM for the services you are performing, because if you don’t know what the new code is, you won’t get paid,” Lewis says.

	Better documentation is absolutely critical for ICD-10-CM coding. Start evaluating provider documentation today, says Renee Stantz, CPC, billing and coding consultant for VEI Consulting Services.  Learn where deficiencies lie and where education is needed to fulfill the ICD-10-CM code requirements. Although some have said that electronic health record (EHR) systems will handle this, many are skeptical. Through regular reviews, most auditors and consultants will tell you that that physicians and NPPs are currently not documenting the necessary information for ICD-10-CM coding. 

	For providers, an assessment will entail reviewing current documentation to evaluate if the required ICD-10-CM detail is included.  The assessment should also incorporate mapping of ICD-9-CM to ICD-10-CM codes for the practice’s frequently-billed codes, and identifying any deficiencies that exist. This exercise will clearly pinpoint specific information that is lacking for accurate coding in the ICD-10-CM world, and allow for parallel provider training and payer testing.  Keep in mind that temporary workflow change-and additional staff-might be needed to conduct this assessment.

	The Centers for Medicare and Medicaid Services (CMS) has estimated that ICD-10-CM training for clinical staff and providers will require 8 to 16 hours, 24 to 40 hours for coders, and 4 to 8 hours for IT staff members. Some form of in-office and classroom training will be necessary for your entire staff, and fostering good communications between providers and coders is essential, Stantz says. All staff involved with dagnosis coding will need to know their training goals and clinical staff will need to understand how their documentation will impact the ability to code.   

	Talk with your software vendor, clearinghouse, billing service, and payers to make sure they are prepared for ICD-10-CM claim testing, Stantz says. Ask your vendor if your practice management and EHR systems will need to be upgraded in order to handle the new diagnostic codes. If so, find out when that upgrade will be finished. Ask your clearinghouse, billing service and each payer if their software can accomodate the new codes and when you can start testing.

	Schedule times to send test transactions, and review results when testing is complete, Stantz says. Some payers are already equipped to accept test claims, so don’t wait to test. If a payer is not ready to test, find out when testing can start. Work out a process in advance to address any glitches. Do not allow your revenue to be delayed because you didn’t test the right way.

So you’ve decided to get your practice ready to use ICD-10-CM coding. Where do you begin? Our experts recommend these steps.

Preparing your practice for ICD-10

The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 outlines the Medicare payment policy for outpatient services performed on the day a patient is admitted to a hospital or for the 3 days before a patient is admitted to a hospital. 

Let's clarify what the 3-day payment window is and to which entities it applies. 

Medicare considers clinically related services preceding an inpatient admission to be part of the "operating costs of inpatient hospital services." Therefore, these services should be included in the hospital's bill for the patient's inpatient stay. 

The technical component (TC) of all outpatient diagnostic services and admission-related, non-diagnostic services provided during the payment window must be included on the hospital's inpatient claim. 

For entities that are wholly owned or operated by a hospital, Medicare will pay the professional component of services with payment rates that include a professional (modifier –26) and technical (modifier –TC) split and the facility rate for services that do not have a professional and technical split. 

2. Services provided within the 3 days (or for psychiatric, inpatient rehabilitation, or long-term care hospitals, 1 day) preceding hospital admission.

This requirement includes services that occur the date of an inpatient admission or during the 3 days (or 1 day) immediately preceding the date of an inpatient admission. 

3. Services rendered by an entity wholly owned or operated by the hospital to which the patient is admitted.

Wholly owned means an entity whose sole owner is the admitting hospital. Wholly operated means the hospital has the exclusive responsibility for conducting and overseeing the entity's routine operations, regardless of whether the hospital has policy-making authority over the entity. 

The hospital is responsible for notifying the entity of an inpatient admission for a patient who received services in a wholly owned or wholly operated entity within the 3-day (or, when appropriate, 1-day) payment window before the inpatient stay. Correct billing is the responsibility of your practice, however, so coordination between the hospital and your billing staff is critical. 

4. A condition clinically related to the reason for the inpatient stay. 

Before this rule was enacted, the ICD-9-CM diagnosis codes had to match for the preadmission services to be included. Now the policy significantly broadens the definition of non-diagnostic services to include any that are clinically related to the reason for the patient's admission, regardless of whether the inpatient and outpatient diagnoses are the same. 

This rule does not apply to services that are distinct or independent from the reason for the patient's inpatient admission. For these services, the professional portion of the service is covered under Medicare Part B, and the technical portion is covered under hospital billing. Additionally, this rule excludes ambulance and maintenance renal dialysis services the hospital provides. 

This month's question asks about the use of modifiers for services performed before a hospital admission. Find out the answer to this pressing coding question.

Modifier needed for services performed before hospital admission

Q: Giving a tuberculosis (TB) test (Current Procedural Terminology code 86580) involves a nurse drawing it up, administering it, examining the arm, and providing documentation to the patient about the result (usually a note that the TB test was negative). I am unsure how to code for this. The reimbursement for the actual medication is around $3.50. It is not a vaccine, so I can't charge a vaccine administration code. Using code 99211 is not always an option. It just seems like so much effort for so little reimbursement. Am I missing something? 

When billing code 86580 on the date the test is administered, use diagnosis code V74.1 (special screening examination for bacterial and spirochetal diseases; pulmonary TB). The Centers for Medicare and Medicaid Services' physician fee schedule says the national payment amount for code 86580 is $7.83. 

If the TB test is positive, then typically you will have a face-to-face visit with the patient to discuss the diagnosis, further evaluation, and treatment options. Use code 99212-99214 (office or other outpatient services). 

Do not code separately for the TB skin test because code 86580 includes the purified protein derivative. 

Q: Would you explain the updates made to the advance beneficiary notice of noncoverage (ABN) instructions?

 The voluntary issuance of an ABN is an option when a service is statutorily excluded from Medicare coverage or as a courtesy to forewarn a patient of his or her financial obligation.  

June 1, the Centers for Medicare and Medicaid Services (CMS) updated its manual instructions and included a "Quick Glance Guide" to ensure you and your staff comply with the ABN issuance requirements (see 

									http://www.cme.hhs.gov/Regulations-and-Guidance/Guidiance/Transmittals/Dowloads/R2480CP.pdf

The author is a medical consultant based in Indianapolis, Indiana.

This month's questions ask about coding for tuberculosis skin tests and noncoverage notice updates. Find out the answers to these pressing coding questions.

Author | Renee Stantz

Articles

Physician documentation audits: Can 1995 and 1997 E/M Guidelines be combined?

Preparing your practice for ICD-10

Modifier needed for services performed before hospital admission

How to code correctly for tuberculosis skin test