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MedaPhase Newsletter - March 2007 [Full Issue]

Emergency Physician Documentation & Billing for Interpretations of EKGs & X-rays
Robert Kottman, MD, FACEP
Medical Director

An underlying principle of emergency medicine is that emergency physicians should bill for the services that they provide. When the services provided are interpretative rather than procedural, this principle remains unchanged. There has long been a reticence on the part of some emergency physicians to bill for the interpretation of EKGs and X-rays, despite the obvious fact that the emergency physician is providing the interpretive service in “real time” - by which is meant “contemporaneously with the patient’s presence in the emergency department” and “the interpretation that directly contributed to the diagnosis and treatment of the patient.”

It is common practice for the cardiologist and radiologist, respectively, to perform a “quality assurance” re-interpretation of an EKG or X-ray that has already been interpreted in “real time” by the emergency physician. This re-interpretation is often performed hours to days after the patient has left the emergency department. Clearly, these are not “contemporaneous” interpretations.

Medicare has long held that, if more than one diagnostic interpretive service is billed to Medicare (by two or more providers) then the Medicare carrier is to determine which interpretation “contributed to the diagnosis and treatment of the patient” and which “was actually quality control”.

NPI Contingency Plan Needed
Lynne Kottman, CCP, CHBME
Legislative Advocate

On May 23^rd, the NPI (National Provider Identifier) will be the required identifier on all claims. While most providers have gotten the message and obtained an NPI, many health plans are not prepared to process claims using this identifier. In addition to this issue, some software vendors have not completed reprogramming for the NPI and many have not completed successful testing.

Organizational Mission and Core Values
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

(Parts 2 and 3 of a 3 part series)

In the last edition of the MedaPhase Newsletter, my article focused on Organizational Vision, a concept that separates successful organizations that have achieved an outward identity of quality and service. Originally my plan was to write three separate articles on Vision, Mission and Core Values. However, this article will cover the concepts of organizational Mission and Core Values as inseparable. The dependency of one to another will be emphasized.

Medicare Payment Schedule - Gaines & Losses
Much has been about the changes in the Medicare fee schedule. The majority of visits for Emergancy Departments are the 5 E&M codes, all but one of which had a gain in 2007.

Physician Quality Reporting Initiative Webpage Now Available
Lynne Kottman, CCP, CHBME
Legislative Advocate

The Centers for Medicare & Medicaid Services (CMS) has announced that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.

According to a CMS press release, "Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services."

News of Note - re PVRP change to PQRI [Full Issue]

2007 Physician Quality Reporting Initiative (PQRI)
Lynne Kottman, CCP, CHMBE
Legislative Advocate

PQRI = New program
PVRP = Old program (which is going away)

Summary from conference call with Sue Nezda, MD, FACEP from CMS

Unchanged from past information:

CMS will pay 1.5% of all Medicare charges including co-pays, not just the charges for items being measured - (she specified that they consider charges to be the Medicare payable amounts.)
Providers will need to report on at least 80% of at least 3 quality measures

Updated information:

News of Note [Full Issue]

Explaining Medicare's Upcoming Pay for Performance
Lynne Kottman, CCP, CHMBE
Legislative Advocate

We have seen a lot of P4P (or PVRP) discussion in journals, and on the internet lately and the question comes up: What do these measures mean to me?

Congress decided that they wanted to follow the business concept of paying more for better performance. In the medical arena, they began looking to hospitals through the Medicare Modernization Act of 2003 to begin reporting on performance measures. In the Emergency Department, one of the standards measured was Aspirin given to patients presenting with Acute MI. In addition to tying the results to payments to hospitals, CMS plans to publish the results (in June) of these performance measures on their website at:

www.hospitalcompare.hhs.gov.

MedaPhase Newsletter [Full Issue]

Vision
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

(1^st of a 3 part series on Vision, Mission and Core Values)

Most doctors’ eyes will likely glaze over when forced into a committee meeting to discuss the vision, mission and core values of an organization. Physicians intuitively know their own individual vision and mission when they don their scrubs and show up for work. They do whatever needs to be done within the scope of their skills and training at the appropriate time. Group practices or hospitals on the other hand need a concerted effort to develop a consensus toward a shared vision of the goals, mission and standards of the entity as a whole.

News of Note: CERT and Medicare
Lynne Kottman, CCP, CHBME
Director of Compliance

CERT Changes

What is CERT? The Comprehensive Error Rate Testing Program (CERT) is the Centers for Medicare and Medicaid (CMS) contract process to monitor the accuracy of claims filed and payments made by the Medicare contractors.

What are the changes? The CERT program has recently changed their time frames for responses to notification.

Medicare Provider Enrollment – Issues potentially impact all providers. This could mean YOU!

What are the issues? NPI implementation, New Provider Enrollment, and Revalidation

Skin and/or Mucous Membranes Repair or Removal
Robert Kottman, M.D.
Medical Director

Significant revenue is lost annually by emergency physicians due to lack of appropriate documentation of skin and/or mucous membrane repairs or debridement/removal of nails (whether toenails or fingernails). The following codes and Texas Medicare reimbursements (applicable to the ‘Rest of Texas’ GPCI—which includes Bexar County) may be helpful in encouraging proper documentation of work done in treatment of emergency department patients with skin, mucous membrane or nail/nailbed injuries.

Coding Corner: Documentation Pearls
Susan Reese, CPC, CCS-P, CCP, ACS-EM
Director of Coding

Physician Documentation Tips & Diagnosis Tips

Addressing Returned Mail
Jason Lott, MBA-HCM
Director of Operations

What percentage of patient mail sent out is returned to your office or billing company due to a bad address? Who is tracking and responding to this increasing and potentially adverse issue that can affect sustained cash flows? With the continuously increasing self pay volumes along with rising insurance based deductibles, copays and expansion of health savings / reimbursement accounts, there are more patients falling into practice billing cycles. To this extent, there is typically a direct proportional increase in non-billable addresses or return mail that must be addressed.

MedaPhase Newsletter October 2006 [Full Issue]

New Orleans Post Katrina - Is the Safety Net Still Intact?
Lynne Kottman, CCP, CHBME

Everyone can remember the riveting scenes of the New Orleans area after the devastation of Katrina and the ensuing floods. Several area Emergency Departments remained opened throughout and now, one year later, the question becomes "How is the emergency medical 'safety net' holding up?"

The Balance-Billing Controversy - Part 1: History
Robert Kottman, MD, FACEP
Medical Director & Legislative Advocate

All around the country, states are addressing an issue that some state legislators view as non-contracted (with health insurance companies) hospital-based physicians “defrauding consumers” by billing them “exorbitant fees” when the health insurers have already paid these physicians very generous “usual and customary” reimbursements - as defined by the insurers. This problem is often characterized as improper “balance-billing”.

Get Reimbursed: Properly Documenting Hypertension
Nancy Maguire ACS, CRT, APC, AFC, CPC, CPC-H
Associate Director of Coding & Compliance

Hypertension is classified as primary or secondary in the diagnosis-coding manual. Hypertension not otherwise specified is assigned to ICD-9-CM code 401.9. If documentation states hypertension without any greater detail, the code assignment is generic (401.9) and does not convey severity. A mild, nonmalignant form of hypertension is termed benign hypertension (401.1). Malignant hypertension (also documented as accelerated hypertension) is another code choice but only if you document by the specific terms malignant or accelerated. If you specify this type, the code changes to 401.0.

Coding Corner: Understanding the Emergency Medicine Caveat

CPT has included a very special exception for key documentation elements that can be found in the definition of E&M code 99285 (Emergency Department Services). This special exception is not included in any other E&M definition.

The fact that this special exemption exists is often overlooked by emergency medicine physicians. The Emergency Caveat is also frequently misunderstood and misused.

News of Note: Payment for X-Ray Interpretations

When the OIG Fiscal 2007 Work Plan was released recently, it contained the following item of concern to Emergency Physicians (underline added):

Inappropriate Payments for Diagnostic X-rays in Hospital Emergency Departments

We will determine the extent of inappropriate payments for diagnostic x-rays performed in hospital emergency departments. In 2004, more than 2.5 million diagnostic x-rays were performed in Medicare-certified hospitals with emergency departments. Interpretations by emergency room physicians of diagnostic x-rays should not be billed separately. We will assess the extent to which Medicare is inappropriately paying for diagnostic x-rays interpreted by emergency room physicians. (OEI; 00-00-00000; expected issue date: FY 2008; new start)

Good News Update

MedaPhase Newsletter September 2006 [Full Issue]

The Uninsured, the Underinsured and the Almost Insured
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

A recent article in an area business journal quoted a Census Bureau report announcing that another 1.3 million Americans have been added to the uninsured roles, totaling 46.6 million nationally. Almost all of the increase in the uninsured came from working adults. Although last year’s annual average increase in premiums was 9.2%, the increase followed four consecutive years of double digit increases. One writer pointed out that it is the low-wage workers who are being hurt the most. Small business owners are responding to these premium increases by dropping their insurance coverage altogether.

Observation Services in the ED
Robert Kottman, M.D., FACEP
Medical Director & Legislative Advocate

Observation services are being increasingly provided by emergency physicians, whether within the ED proper or at a different site within the hospital. Observation services may be provided in any bed in any part of the hospital, including the ED. Observation is not a location, but a status.

If an ED bed is to be utilized for provision of observation services, the physician providing observation services must:

Taking a Patient History
Nancy Maguire ACS, CRT, APC, AFC, CPC, CPC-H
Associate Director of Coding & Compliance

The three key elements in selecting the appropriate level of E&M code are history, physical examination, and medical decision-making. Medical decision-making (MDM) drives the history and physical exam. These elements must meet or exceed the minimum requirements specified by CPT. When determining the level of history for an E&M code, the documented elements in the History of Present Illness (HPI), Review of Systems (ROS), and/or the Past, Family, Social History (PFSH) determine the level of history performed.

Featured Consultant: Irma Nin, M.D.

Evidence Based Clinical Orders

Emergency Departments are increasingly being forced by their administration to focus on improving “Through-Put” times. One of the areas that can positively impact this goal is the streamlining of the ordering process. Dr. Irma Nin, M.D., an emergency physician from Venice, Florida has developed, both from experience and published literature, an Evidence Based cost effective system for the ordering process.

Coding Corner: Documentation of Laceration Repairs

Single Layer Closures: With a single layer closure, please document carefully for the work being done and state the length of the wound in cms.

Intermediate Upgrade: If the wound is heavily contaminated requiring extensive cleaning or removal of foreign matter it can be coded and billed as an Intermediate Laceration repair instead of a simple repair.

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