Feb 11, 2021 | Uncategorized
The 2021 E/M updates and elements of MDM are continually being clarified. The article below will address questions and answers over the new E/M Office visit guidelines. Read below to see more about the new updates and information. nnBy Ginger Avery, CPC, CPMA, CRC nFebruary 2, 2021nnQuestions and answers continue to be clarified as we are now a month into utilizing the new E/M Office Visit guidelines that took effect on January 1, 2021. Understanding how to navigate labs and other test results as they pertain to the time and medical decision-making (MDM) elements of the revamped E/M office visit rules can be hard to ascertain. The following details should help improve understanding of the new data review rules. nnData Element:nn
n
- When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits?n No. When a clinician orders a test during an E/M visit, the order and review of the test result will count toward the MDM of the first encounter.
n
- If we receive a test result two days after the visit, can we count a data point toward that E/M visit for review of the test?n Yes, there’s pre-service work and post-service work associated with the encounter and receiving a test result a couple of days later and responding to it are part of the post-service work of the encounter.
n
- Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?nPer AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Clinician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The clinician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.
n
- If one doctor orders a test that is performed in the practice, but a second doctor bills for the test, can the first doctor count the test order toward MDM for his visit?nPractices should not count a test toward MDM if the ordering practitioner’s practice also performed and billed for the test. Medicare and private payers could view that type of coding as abusive or fraudulent.
n
nDocumentation Questions:nn
n
- Since history and physical exam are no longer required to level the visit, should these elements still be documented?nYes, history and exam are still part of an evaluation. The documented content should be focused only on the clinically relevant details and cognitive thoughts of the clinician. Document the nature of the presenting illness(es) (subject details with pertinent ROS). Document a medically necessary exam. Documentation is about the quality of the story, not the quantity of details. Avoid importing pages of past medical history, ROS or medication lists that are note relevant or helpful. Clinicians are encouraged to write clear stories that they would like to read.
n
- Do I still have to document ROS and PFSH?nYes, when clinically relevant. For example: Patient presents with chest pain. Has been having intermittent chest pain at rest for two weeks. No notable triggers. Positive for headaches and dizziness, no SOB. Patient has a family history of CAD. Remember, documentation is all about the medically necessary story.
n
- When coding based on total time does the assessment and plan still need to be documented?nYes. Quality documentation should always be captured. Clear stories that include clinical impressions and plans support the medical necessity and describe the complexity for the services provided, regardless of how you choose to report the visit.
n
nOther Common Questions:nn
n
- Are commercial plans required to adopt the revisions to E/M codes?nYes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, they should have implemented these revisions Jan. 1, 2021.n
n
- Do the 2021 E/M code and guideline changes apply to all categories of E/M services?nNo. The E/M code and guideline changes are specific for office and other outpatient visits and apply only to codes 99201–99205 and 99211–99215. Inpatient services still need to follow the key component guidelines (1995 or 1997).n
n
- When considering High-Risk MDM, there is an example listed: “drug therapy requiring intensive monitoring for toxicity”. What constitutes supporting this definition? When considering this complexity, both the drug and the monitoring must qualify. The new guidelines provide this definition when considering this High-Risk example:n“Drug therapy requiring intensive monitoring (today) for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Both the drug and the monitoring must qualify on the date of the encounter.n
n
- Where can the CPT E/M code and guidelines be found?nThe CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations’ (AMA) site at this link. They can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include details about reporting based on the total encounter time, the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean.
n
nAs a reminder, documentation is about painting a clear picture of each encounter. The power of storytelling is evident with these new updates. Quality documentation provides details to support and defend the medical necessity and appropriate complexity of each unique encounter, as well as improves overall patient care and clinical outcomes. Due to President Biden recently issuing several health care executive orders, we can expect policy adjustments that will lead federal auditors and investigators to focus on subjects like: fraud and abuse (especially in the telehealth arena), auditing of provider relief funds received during the PHE, HIPPA compliance, meaningful use, workplace safety and Evaluation and Management (EM) services. With increased emphasis on these interrelated topics, clinicians are encouraged to focus documentation efforts on the cognitive clinically relevant details, regardless of the clinical setting. Document what you do, code what you document. Consider an educational audit review for your clinicians to see if they are taking proper credit for all the work they do by telling great stories in their encounter notes.nnKeep an eye out for more guidance from Medicare and private payers. Currently, Medicare is still working on an update to its documentation guidelines for E/M services. Welter Healthcare Partners provides robust coding and documentation training for these updates, as well as other topics. Please contact cwhitworth@rtwelter.com to book your training now.nnReferences:nAMA CPT® E/M Code and Guideline Changes for 2021nAma-assn.orgnNovitas E/M Documentation RequirementsnNoridian E/M Documentation RequirementsnDecision Health PartBNews
Feb 11, 2021 | Uncategorized
The report below describes a patient undergoing excision of the left dorsalis pedis artery aneurysm. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed and to learn about the use of the unlisted procedure code for this cardiovascular procedure.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. n
– Click Here to Submit Redacted Surgery Case Study –
nn
nn37799: EXCISION DORSALIS PEDIS ARTERY ANEURYSM [COMPARE TO CODE 35152 FOR UNLISTED PROCEDURE] I72.4nn
nDATE OF OPERATION: 01/XX/2021nOPERATING SURGEON: S. G., M.D.nPREOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPOSTOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPROCEDURE PERFORMED: Excision of left DP artery aneurysm.nANESTHESIA: Monitored anesthesia care with local anesthetic.nASSISTANTS: None.nINDICATION: The patient is a 40-year-old male with a history of acute onset of left foot pain. Ultrasound demonstrated a pseudoaneurysm versus aneurysm of the dorsalis pedis artery. The patient did not have any blue toes but based on the symptoms of pain and the location, it was recommended he undergo excision. Risks, benefits, and alternatives were discussed with the patient. He consented to procedure.nnDESCRIPTION OF PROCEDURE: On the operative day, the patient was met in the preop holding area. All site verification consent forms were completed and placed in the chart. The patient was then taken to the OR, placed on table in supine position. After induction of general anesthetic, the patient was prepped and draped in usual sterile fashion. Final time-out was then performed by all in attendance to be correct patient, correct procedure, correct site, and the antibiotics had been administered. Using ultrasound, the anterior tibial and dorsalis pedis artery were mapped. Of note, right at the ankle, the dorsalis pedis branched into a medial and lateral branch. The lateral branch was the one that proceeded on to the aneurysmal region. This area again was marked on the skin. At this point, a sterile pulse ox was placed on the great toe and hooked up to the machine for continuous monitoring. An incision remained over the marked area after the area was anesthetized with lidocaine and Marcaine mix. This was carried down through soft tissue using electrocautery. The retinaculum was identified and divided and neurovascular bundle exposed. The dorsalis pedis just distal to the medial branch was vessel looped and a test clamp was performed. This resulted into no deficit of the waveform or pulse oximetry reading in the great toe. Additionally, he had excellent color and signal distal to this test ligation. At this point, I traced distally along the artery until the aneurysmal portion was identified. It was noted that there was no Doppler signal or flow within this vessel in this position. At this point, I then carried the incision down to more normal appearing vessel and then placed 2 clips. This was then removed and opened on the back table revealing some atheroma. At this point, the incision was irrigated. Hemostasis was assured. It was closed in multiple layers with Vicryl and a Monocryl suture. Sterile dressing was applied in addition to Steri-Strips. The patient tolerated the procedure well. No complications.nnESTIMATED BLOOD LOSS: 5 cc. TOTAL FLUIDS: 600 mL.nTOTAL LOCAL: 9 mL.nSPECIMEN: Left dorsalis pedis artery to pathology.
Feb 4, 2021 | Uncategorized
What will the “Next Haven Healthcare” look like? Let’s ask the professionals! After the failed joint venture announced the disbanding of the employer healthcare, you may have questions about the future of employer healthcare and what it might look like. Speaking to five healthcare executives, continue reading below to see what they said about the future of employer-provided healthcare. nnHealthcare executives share their thoughts on how the next big disruptor will be perceived by the industry and the steps that organizations will need to take to succeed. It was only three years ago that Amazon, Berkshire Hathaway, and JPMorgan Chase joined together to form Haven Healthcare in an effort to improve employee healthcare options. When Haven was initially announced, it was surrounded by media fanfare and many thought the joint venture would disrupt the healthcare payers market. However, the business giants announced last month that Haven would disband by the end of February. Speculation around why the joint venture failed include lack of traction towards goals, unfocused execution of organizational strategy, a high turnover rate in the C-suite, and the fact that disruption healthcare is not an easy feat. Haven is not the first company to attempt to disrupt the healthcare industry and it certainly won’t be the last. Given the likelihood that another company will attempt to be the ‘next Haven,’ HealthLeaders spoke with five healthcare executives about how the next big disruptor will be perceived by the industry and what steps such an organization should take to succeed in this tough endeavor.nn‘ABSOLUTE AND MANIACAL TRANSPARENCY’nnAshok Subramanian, CEO of Centivo, an employee health plan, says he believes the next Haven, or an organization that self-styles itself as the next Haven, will be “viewed skeptically.” “Given that Haven tried to come out with great fanfare, and then was not able to be successful, naturally breeds skepticism,” he says. Subramanian adds that there is growing skepticism among the provider community of employers following a top-down approach to healthcare reform and “declaring that they are going to be successful.”nn”What we are seeing is enthusiasm for more bottom-up approaches, employers working with organizations to take matters into their own hands,” he says. “That, like a lot of community-driven efforts, will probably be viewed more positively than any organization that would at least label itself as the next Haven.” Subramaniam suggests organizations should focus on transparency and the “true spirit of the partnership.”nn”Nothing in this industry can successfully move the needle without a commitment to absolute and maniacal transparency around financial flows, around data, around understanding that ultimately employers who are self-funded are responsible for their own health plans. And that was one of the greatest failures of the first Haven,” he says. According to Subramaniam, organizations should collaborate “community by community” with providers that have committed to move the industry towards value-based care and willing to “collaboratively partner with agents of change.” He says these organizations are accepted over “large organizations who feel like they can fix these things on their own.”nnHAVEN’S DEMISE BREEDS CAUTIONnnMichael Abrams, managing partner and co-founder of Numerof & Associates, a healthcare management consulting company, says he also believes the next big industry disruptor will be viewed with uncertainty. “In many ways, I think the demise of Haven made it that much more difficult for any organization to claim that same mantle,” Abrams says. “They brought so much firepower to their announced mission of more or less fixing healthcare, that now that they’ve closed their shop, the industry may very well take it as an admission that the problem is just not solvable, because it couldn’t be solved by those superstars.”nnHe also says that while obstacles remain, there is no lack of disruptors currently working in the market. “There is a long list of disruptors that are working to come up with innovations that will make the money, and in most cases, lower the cost of care,” he says. Among those disruptors, Abrams explained, are Amazon, (which was one-third of the partnership behind Haven), and the U.S. government. To disrupt and change healthcare, he says organizations need to look towards those who are making waves in the industry. “To change the rules of the game will take a level of political will,” Abrams said. “That is the closest approximation to a big idea and will actually change healthcare.”nnNEED A UNIFORM STRATEGYnnWhen it comes to healthcare disruptors, Craig Maloney, CEO of Maestro Health, a third-party administrator for employee benefits, says he believes the focus should be on the members served. “I’m a big believer in starting with the consumer,” Maloney says. “So many of the end users, whether it’s my 80-year-old mother, the Gen Xers, or even people in healthcare [have] so much confusion. Anybody coming into this space needs to be able to impact that digesting healthcare on a daily basis.”nnHe adds: “You also have to serve the employer groups, since they’re the drivers of so much of the healthcare delivery out there today. Anytime you talk about transformation; it comes with risk. You need to be able to digest that risk, and tolerate that risk, to facilitate change.” Maloney says for the next big disruptor to succeed, they should have a uniform strategy, a focus on not only technology but also on “the human side of things” and “the wherewithal to commit” for a long period of time. “Haven proved out that three years is not a long commitment in terms of disrupting such an established, complex, and even odd industry,” Maloney says. “When [I] talk to other organizations who are looking to impact and change healthcare, [they’re looking at a 10-, 15-, or 20-year commitment.]” When organizations are first starting out, Maloney suggests they start small instead of starting big.nnFOCUS ON THE CUSTOMER EXPERIENCEnnMark Nathan, CEO of Zipari, a technology company specialized in health insurance, says the next big disruptor should work in conjunction with payers and providers to succeed in their mission of disrupting the healthcare space. “Payers and providers have to be part of the equation,” Nathan says. “Payers and providers have made huge investments in their systems. There’s a lot of regulation and emphasis on keeping everything running efficiently, but not a lot of emphasis on innovation. And so, to build that next generation of disruption for healthcare, they have to be at the table solving the problem.”nnHe also says there should be a focus largely on customer experience to succeed, including consistent communication and messaging. “The patient at the center of everything,” Nathan says. “We have to get that alignment between the payers, the providers, and a patient. No matter where the member engages with the payer, they should get a consistent message that’s going to … improve their health. If payers get that message up to their members, then the payer brands will start to improve, their Net Promoter Score will start to improve because they’ll be trusted. That’s something that’s missing in this industry that is critically important.”nn‘VERY PESSIMISTIC’ ABOUT THE NEXT HAVENnnSteven Goldstein, MD, founder of Houston Healthcare Initiative, a website which offers resources to people and organizations who want to change the current healthcare industry, is not optimistic for disruptors who want to change the current healthcare system through technology and innovation.nn”If we go back to first principles, the primary purpose of healthcare is to keep patients well,” Goldstein says. “The secondary purpose is to care for people when they get sick. But our current system is backwards, it primarily cares for the sick, and only secondarily tries to keep the patients well. The current system of managed care frowns on innovation. In my opinion, delivery of medical care lags the technology by about 25 years. They’re not innovative, they don’t want to change the system, and that’s the problem.”nnGoldstein notes that it is difficult for disrupters to succeed in the current system. “I’m very pessimistic that we’re going to get much innovation, like the Haven ideas, accepted by the healthcare industry in the current way it’s set up,” he says.nn nnOriginal article published on healthleadersmedia.com
Feb 4, 2021 | Uncategorized
Johnson & Johnson’s new Covid-19 Vaccine awaits approval and it is important to look at the coding and billing ahead of time. New vaccine CPT codes have been released for the vaccine and staying up to date will keep you in best practice once the vaccine is distributed. Read below to get the full story. nnAs new COVID-19 vaccines continue to be approved and distributed it is important to make sure you are correctly coding, and billing based on the vaccine given.nAhead of the approval of the new Johnson and Johnson COVID-19 vaccine, the AMA has added a new CPT code 91303 (Severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [COVID-19] vaccine, DNA, spike protein, adenovirus type 26 [Ad26] vector, preservative free, 5×1010 viral particles/0.5 mL dosage, for intramuscular use).nnIn addition to this new vaccine code, there is also a new HCPCS code 0031A (Immunization administration by intramuscular injection of SARS-CoV-2 [COVID-19] vaccine, DNA, spike protein, Ad26 vector, preservative free, 5×1010 viral particles/0.5 mL dosage, single dose) for administration.nnThis code will take affect immediately following approval of the vaccine by the Food and Drug Administration (FDA). As of this writing, it is still pending approval.
Jan 28, 2021 | Uncategorized
nnWhat the rev cycles need to know about the “No Surprises Act” can help with understanding the new legislation coming January 2022. The legislation is set to protect patients from surprise medical bills and provide protections within network care. Continue reading below to keep yourself updated on the new legislation. nnJust as revenue cycle executives are coming up for air from the CMS price transparency mandate, they have another date to add to their compliance calendar: January 1, 2022. That’s the day that the No Surprises Act goes into effect. The legislation has two main parts. First, it protects patients from surprise medical bills. “Under the recently announced No Surprises Act, patients will only have to pay the in-network cost-sharing responsibilities for their care, while payers and providers will negotiate payment for the rest,” Rob LaHayne, CEO of TouchCare, a healthcare concierge service, tells HealthLeaders via email.nnThe No Surprises Act also establishes an independent dispute resolution (IDR) process for payers and providers. “It takes consumers out of the middle of the dispute between the payer and the provider,” says Becky Greenfield, partner with Wolfe Pincavage, a Miami law firm specializing in healthcare, insurance coverage, and business law.nnARBITRATION 101nThe IDR will use a “baseball-style” arbitration to settle disputes between payers and providers. Each of the parties will offer a payment amount, and an independent arbitrator will choose one offer or the other, rather than an amount in between. “That incentivizes those parties to [each] make a reasonable offer,” Greenfield says. This so-called “final-offer arbitration” process can help prevent the parties from making bids that are either too high or too low.nn”The incentive created by arbitration brings some elements of market dynamics into the dispute-resolution process,” says Benjamin L. Chartock, associate fellow at the Leonard Davis Institute of Health Economics and lead author of a recent Health Affairs study about arbitration in out-of-network medical bill payment disputes in New Jersey. “A more extreme offer by one of the parties in arbitration helps them financially if they win but might lower the probability that they win.” In advocating for a dispute resolution process, hospitals had been pushing for arbitration, whereas payers had called for benchmark payments, such as ones tied to median in-network rates.nn”This process edges the surprise billing issue closer to the dispute resolution and regulatory structure common in many of today’s workers’ compensation structures, where most states removed patient liability well over two decades ago,” notes Scott Bennett, vice president of access innovation at Maestro Health, via email.nnCONSUMER PROTECTIONSnFrom a consumer perspective, the No Surprises Act essentially makes out-of-network balance billing a thing of the past. That’s especially important for patients who live in states that don’t already have such protections in place. According to the Commonwealth Fund, 18 states have no balance billing protections in place. The rest have comprehensive or partial protections. “It requires that insurers apply the in-network, out-of-pocket benefits to emergency services and [to] out-of-network services in in-network facilities,” Greenfield says, such as services provided by an out-of-network anesthesiologist working in an in-network facility. “Not only can you not be billed the difference between what the insurer pays and what the provider bills, you also cannot apply out-of-network deductibles to these types of services,” she says.nnAccording to an announcement from the U.S. Senate Committee on Health, Education, Labor & Pensions, the legislation:n
n
- Holds patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts, including deductibles, in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider
n
- Prohibits certain out-of-network providers from balance billing patients unless the provider gives the patient notice of the network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care
n
- Provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers
n
- Provides a true and honest cost estimate that describes which providers will deliver their treatment, the cost of services, and provider network status
n
nREVENUE CYCLE CONSIDERATIONSnAlthough the legislation won’t go into effect for nearly a year, there are things that revenue cycle executives should be thinking about and working on as they prepare.nn1. Establish processes to end balance billing: “First and foremost—especially if you’re not in a state that already has balance billing protections—you need to establish a process to make sure that patients are not balance billed,” Greenfield says.nn2. Get ready to provide estimates: Providers also must prepare to give patients a “true and honest cost estimate.” “Those processes need to be in place,” according to Greenfield. “[Revenue cycle] staff needs to be trained on this as well to make sure that they’re compliant, because there are civil monetary penalties involved for noncompliance.”nn3. Remember that arbitration costs money: Chartock notes that “arbitration is not free,” so providers need to consider their dispute resolution options. “Disputing parties have the option as well to resolve these payment disputes for out-of-network bills offline and, if I were in a situation like that, I would carefully consider doing that as well,” he says.nn4. Pay attention to the details: Although the No Surprises Act was signed into law, more details are still coming. For example, the Commonwealth Fund notes that “Federal officials will have to establish a list of eligible arbitrators and help interpret the factors that will guide arbitrators’ decisions.” “There is still a rule-making period that must take place between the passage of the law and when it begins to take effect,” Chartock says. “We know the text of the law, but not the intricate details of how the law will be enacted.”nn nnOriginal article published on healthleadersmedia.com
Jan 28, 2021 | Uncategorized
January is National Mentorship Month! This is the month of the year to celebrate mentorship for professional and personal development for individuals across the United States. As we wrap up January, think of how mentors in our lives have impacted us and how we can continue to mentor the future to make our communities stronger and healthier.nnOne of my favorite quotes; “We learn… 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we both hear and see, 70% of what is discussed, 80% of what we experience personally, 95% of what we teach to someone else” -William Glasser.nnEach year as you look to the future and the goals you hope to achieve in the new year, one cannot overlook how your goals can be enhanced through mentorship. Whether you choose to be a mentor or request mentorship from some else it is a great opportunity to gain knowledge and camaraderie in your goals and support someone else in theirs.nn“A mentor is someone who sees more talent and ability within you, than you see in yourself, and helps bring it out of you.” -Bob Proctor.n
