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Practice Management Issues

February 27-28, 2015

Vanessa Lankford, CPC, CMCO, CMOM, AACE-CECAHIMA Approved ICD10-CM TrainerPractice Management Coordinator

American Association of Clinical Endocrinologists

American Association of Clinical Endocrinologists

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All medical coding must be supported with documentation and medical necessity. 

**While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will recognize and

accept the coding and documentation recommendations.  As CPT®, ICD-9-CM and HCPCS codes change annually, you should reference the current CPT®, ICD-9-

CM and HCPCS manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information.

This information is taken from publicly available sources.  The American Association of Clinical Endocrinologists cannot guarantee reimbursement for

services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement.  This information is intended for

informational purposes only.  Current Procedural Terminology (CPT®) is copyright and trademark of the 2014 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS

restrictions apply to government use.

General Disclaimer

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Learning Objectives

• Manage the need for prior authorization in terms of reimbursement

• Evaluate report requirements for billing

• Determine coding for coverage

Prior Authorizations for Bone Mass Measurements

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What are they?What are they?

A request by a provider to a patient’s carrier for approval of a service to be performed prior to being

performed

Why are they needed?Why are they needed?

- used to determine medical necessity

- potential cost savings for the patient/carrier

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Prior Authorizations (PAs)

Why would PAs be unapproved?Why would PAs be unapproved?

Not enough time allowed for process to be completed Incomplete formsMissing requested information

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Prior Authorizations (PAs)

Why would PA services be denied?Why would PA services be denied?

- missing PA number on claims

- incorrect procedure/diagnosis code

- eligibility of patient

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Prior Authorizations (PAs)

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Management of Prior Authorizations

• Utilize Carrier’s Web Portals

Review patient eligibility/plansCapability of online prior authsEstimation of plan reimbursements (HSA)

Maintain top payers authorization requirements

• Who are top 5-10 payers• “Hands on” the contracts

Find it!!!!!!!!!!!!!!!READ the contractDetermine when it was last updated…What procedure and/or diagnosis codes are

allowed?Other requirements?

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Management of Prior Authorizations

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•Maximize EHR Capabilities• ? Patient reminders/alerts/pop ups• ? “in-house "communication (keeps patient informed of upcoming potential costs)

•Centralize responsibilities in office•Analyze work flows in office•Designate ownership

•?Check in/out, biller, coder, scheduler•Educate- support- policies

Management of Prior Authorizations

Prior Authorizations

Do NOT guarantee reimbursement

Reimbursement is based on:-Patient eligibility

-Carrier policies and contracts

-Medical Necessity supported in the documentation-Correct coding of the services (that were provided & documented)

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*Document FIRST…

Code SECOND

Code what was documented

Do not document to code!

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Medical Necessity and

Report Requirements

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General Report Requirements

Report should be legible and permanent

Diagnosis, sign, or symptom clearly indicatedDon’t use “rule-out”, “looks like”, “suspect” for physician diagnosis coding

If it’s a follow up- ?Revisions of diagnosis

Name, date of birth and date of service ON EACH PAGE

Back & Front

Signed/authenticated by provider

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Complete

Clear

Consistent

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• Legal document

• Help minimize or prevent malpractice suits

• Communication

• Statistics

• Billing/ Medical Necessity for services

performed

= Reimbursement

Documentation…

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The disconnect…

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Medical Necessity

Medicare’s Definition of Medical Necessity:

In the Federal Register Medicare defines reasonable and necessary as

“for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

42 u.s.c. 1395y(a)(j)(1)(A).”https://www.aace.com/sites/default/files/Federal-Register-OIG-Compliance.pdf

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MLN’s Basic Medicare Information for Providers and Suppliers Booklet Chapter 4 also adds,

Meet standards of good medical practiceProper and needed for the diagnosis or treatment of the patient’s medical conditionNot mainly for the convenience of the patient, provider or

supplier

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Basic-Medicare-Information-for-Providers-and-Suppliers-Guide-ICN005933.pdf

CMS adds

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Carrier’s Contracts and Policies

Reimbursement is based on…

Carrier contracts may vary from:state to state (commercial & federal contractors)

hospital to hospital (teaching/for profits)

physician to physician patient to patient (traditional, PPO,HMO, HSA)

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Remember…

State to State….

• Scopes of practice for mid levels, RNs, techs and other clinical staff

• Medicaid and other state sponsored funds

• Medicare Administrative Contractors (MACs)

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Medicare Administrative Contractors (MACs)

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• Process Medicare claims (Medicare Part A/B)

• Enroll health care providers in the Medicare program

• Educate providers on Medicare billing requirements

• Answer provider and beneficiary inquiries

• http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MACContractStatus.html

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Who’s your MAC?Who’s your MAC?http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-

compliance-interactive-map/index.html

Complete List of MACs http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/

Downloads/MACs-by-State-January-2015.pdf

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NCDs = National Coverage Determinations

LCDs = Local Coverage Determinations

Decisions by Medicare and their administrative contractors (MACs) that provide coverage information and determine whether services are reasonable and

necessary

Commercial carriers may have national and/or local coverage determinations.

Check commercial contracts for special administrative guidelines for services, procedures, and supplies.

Most commercial carriers follow Medicare’s guidelines at some level

Medicare Policy

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• NCDs mandated at national level • all FIs, Carriers, and Medicare Administrative

Contractors (MACs) follow

• LCDs mandated at MAC level• Only applicable to that MAC’s jurisdiction• Not all MACs have the same LCD• LCDs on the same service/procedure/supply may vary based on

the MAC

What’s the difference in an NCD and LCD?

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Covered CPT/HCPCS

ICD9-CM/ICD10-CM codes considered reasonable and necessary

Frequency limitations

Documentation requirements and/or what clinical circumstances a service is considered to be reasonable and necessary

Administrative and educational tools to assist providers in submitting correct claims for reimbursement

Information provided on NCD/LCD

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The Provider Compliance Group Interactive Map allows access to state-specific CMS contractor contact information and includes LCDs for the area.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html

General NCD/LCD Information

Medicare’s NCD 150.3

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NCD for Bone (Mineral) Density Studies (150.3)

Conditions for coverage of bone mass measurements are now contained in chapter 15, section 80.5 of Pub. 100-02, Medicare Benefit Policy Manual .

Claims processing instructions can be found in chapter 13, section 140 of Pub. 100-04, Medicare Claims Processing Manual .

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70BP.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf

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Medicare’s NCD for Bone Density Studies

Conditions of Coverage (not an all inclusive list)

Must be ordered by the physician or qualified non-physician practitioner who is treating the beneficiary  (qualified non-physician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives)

Performed under the appropriate level of physician supervision

Reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets qualified conditions

 

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Frequency Frequency

Allows a screening bone density screening bone density once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).

When medically necessary, Medicare may pay for more frequent bone density studies Examples include, but are not limited to, the following medical circumstances:

Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.Confirming baseline BMMs to permit monitoring of beneficiaries in the future.

 

Medicare’s NCD for Bone Density Studies

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Screening verses Diagnostic Services

Screening = testing for disease in seemingly well person so early seemingly well person so early detection and treatment can be provided. detection and treatment can be provided.

Diagnostic=testing to rule out or confirm a suspected diagnosis

because the patient has a sign or symptompatient has a sign or symptom

See ICD9-CM Section I. C.18. 5 for complete guidelines for coding for screening and diagnostic services.

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Following Correct Coding and Billing Guidelines

Reimbursement also depends on…

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CPT code = Procedure or service

ICD9/ICD10 CM code = Sign, symptom or definitive diagnosis

CPT and ICD9/ICD10-CM codes are reported based on the documentation and should be coded to the highest level of specificity

Claims submitted to carriers must have:

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77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine), including vertebral

fracture assessment

Do not report 77085 with 77080 or 77086

77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

Do not report 77086 with 77080 or 77085

= New Code = New CodeNEW 2015 CPT ® Codes

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77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

77079 has been deleted

77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g. hips, pelvis, spine)

Do not report 77080 with 77085 or 77086

77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;

appendicular skeleton (peripheral) (e.g., radius, wrist, heel)77082 was deleted- see 77086

For DXA body composition study use 76499 (unlisted diagnostic radiographic procedure)

CPT ® Codes Green font indicates new verbiage in CPTThese codes are still active

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Professional, Technical, Global

Bone mass measurements have a professional (physician)

and technical component.

This means that part of the procedure was performed by the physician

& another part of the procedure was done “technically”.

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Technical or Professional Modifiers

Affect payments

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If the procedure is billed without a 26 or TC, it’s considered “global” billing.

77080

This type of billing indicates the physician owns the equipment, pays for the technical staff, and performs the supervision and

interpretation and provides a written report.

Global

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Medical Necessity for BMM

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Check commercial carriers to determine their administrative guidelines regarding services, procedures or modifiers

Coding/billing/reimbursement/administrative guidelines varies between: Local commercial contracts

• Physician to physician- hospital to hospital State

• Scopes of practice may vary for mid-levels Federal Medicare Administrative Contractors (MAC)

Check with compliance and/or coding departments the office and/or hospitals or other facilities where patients are seen to determine if there are additional or further guidelines required to be followed by providers and/or staff

who provide services and/or supplies to patients.

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Medical Necessity

Medicare’s Definition of Medical Necessity:

In the Federal Register Medicare defines reasonable and necessary as

“for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

42 u.s.c. 1395y(a)(j)(1)(A).”https://www.aace.com/sites/default/files/Federal-Register-OIG-Compliance.pdf

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If it’s not documented, If it’s not documented, it wasn’t done!!it wasn’t done!!

– NO ASSUMPTIONS WILL BE MADENO ASSUMPTIONS WILL BE MADE

can NOT code based on protocolscan NOT code based on protocols

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Personal historyPersonal history- past medical condition no longer exists and patient is not receiving treatment – but has potential for recurrence and may require continued monitoring

Family historyFamily history codes are used when a patient’s family member(s) have had a disease that causes the patient to be at a higher risk for contracting the disease.

History Diagnosis Codes

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Common Diagnosis Codes

ICD9 Code

Description ICD10 Code

Description

Z87.310Personal history of (healed) osteoporosis fracture

Z82.62 Family history of osteoporosis

Z82.61 Family history of arthritis

Z87.311Personal history of (healed) other pathological fracture

Z87.312 Personal history (healed) stress fracture

V87.43 Personal history of estrogen therapy Z92.23 Personal history of estrogen therapy

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Screening verses Diagnostic Services

Screening = testing for disease in seemingly well person so early seemingly well person so early

detection and treatment can be provided.detection and treatment can be provided.

Diagnostic=testing to rule out or confirm a suspected diagnosis

because the patient has a sign or symptompatient has a sign or symptom

See ICD9-CM Section I. C.18. 5 for complete guidelines for coding for screening and diagnostic services.

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ICD9 Code

Description ICD10 Code

Description

V82.81

Screening for osteoporosis (use additional code to identify hormone replacement therapy (postmenopausal) V07.4 or postmenopausal (age-related) (natural) status V49.81)

Z13.820 Encounter for screening for osteoporosis

Common Diagnosis Codes

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ICD9 Code

Description ICD10 Code

Description

V58.83

Encounter for drug monitoring (use additional code for long term drug use)

Z51.81Encounter for therapeutic drug level monitoring (code also any long term (current) drug therapy (Z79.1-)

Z79.810Long term (current) use of selective estrogen receptor modulators (i.e. Evista, Volvadex, Fareston)

Z79.818

Long term (current) use of other agents affecting estrogen receptors and estrogen levels (i.e. estrogen receptor downregulators, Faslodex, GnRH, Zoladex, leuprolide, Lupron, Megace)

Common Diagnosis Codes

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ICD9 Code

Description ICD10 Code

Description

V49.81Asymptomatic postmenopausal status (age related or natural)

Z78.0 Asymptomatic menopausal state

N95.1

Symptomatic menopausal state (symptoms such as flushing, sleeplessness, headache, lack of concentration, associated with natural (age related) menopause) (USE additional code for associated symptoms)

V07.4Hormone replacement therapy (postmenopausal)

Z79.890Hormone replacement therapy postmenopausal

Common Diagnosis Codes

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ICD9 Code

Description ICD10 Code

Description

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

733.00 Unspecified osteoporosis See Categories M80 – M81

Osteoporosis with and without pathological fracture

733.01 Senile osteoporosis (post menopausal)

See categories M80 – M81

Osteoporosis with and without pathological fracture

733.02 Idiopathic osteoporosisSee categories

M80 – M81Osteoporosis with and without pathological fracture

733.10 – 733.19

Pathologic fracturesSee categories M84.4 –M84.68

Pathological fractures

733.09 Drug induced osteoporosisSee categories

M80 – M81Osteoporosis with and without pathological fracture

252.00 – 252.08

HyperparathyroidismSee category

E21Hyperparathyroidism and other disorders of parathyroid glands

268.X Vitamin D deficienciesSee Category

E55Vitamin D deficiency

Common Diagnosis Codes

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Physician services are not paid based on diagnosis code(s).

Inpatient services are paid based on diagnosis code(s).

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• Code updates, deletions, changes and revisions are published and effective each October 1each October 1stst

• ICD10 Codes and Conventions are available for FREE on the internet

http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html

ICD10-CM is effective October 1, 2015

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Adherence to guidelines for coding Adherence to guidelines for coding

and reporting are required under and reporting are required under

HIPAA in all healthcare settings!HIPAA in all healthcare settings!Page 1 Draft official guidelines for coding and reporting

Reason to Capture Codes Appropriately

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Be open to change- Be open to change-

remember- everyoneeveryone who is a covered HIPAA

entity has to move to this code set

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Don’t wait until Don’t wait until

the last minute the last minute

to make to make

changes…changes…

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• Increased claim rejections• Denials• Increased delays in processing authorizations • Improper claims payments• Coding backlogs• Compliance issues• Incorrect decisions that are based on diagnosis

data

Consequences of Poor Preparation

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Reimbursement, Denial & Appeals

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CPT 2015 2014 Work RVU

77078 $114.06 $114.27 .25

77080 $41.48 $49.44 .20

77081 $28.25 $27.94 .22

*77085 $56.49 .30

*77086 $35.75 .17

National Medicare Global AllowableNon-Facility

*New CPT® codes for 2015

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Reimbursement, Appeals, Denials

Check commercial carriers to determine their administrative guidelines regarding services, procedures or modifiers.

Coding/billing/reimbursement/administrative guidelines varies between:

– Local commercial contracts

• Physician to physician- hospital to hospital

– State

• Scopes of practice may vary for mid-levels

– Federal Medicare Administrative Contractors

Check with compliance and/or coding departments the office and/or hospitals or other facilities where patients are seen to determine if there are additional or further guidelines required to be followed by providers and/or staff

who provide services and/or supplies to patients.

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Medicare Advance Beneficiary Notices (ABN)

Issued by providers to Medicare beneficiaries in situations where Medicare payment is expected to be denied.

Provided BEFORE the service is renderedOrdering, referring, or performing provider may provide to patientABNs forms are in English and Spanish

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Number of copies required Reproductions Length and size of paper Contract of paper to ink Fonts Customization Retention

Common Challenges with ABNs:Patient refusal to sign ABNPatient changes mind

ABN requirements & restrictions

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Medicare Claims Processing Manual, Chapter 30, Section 50

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-CMS-Manual-Instructions.pdf

Additional information on Fee for Service ABN of Non-coverage

•ABN forms in English and Spanish•ABN form Instructions•ABN CMS Manual Instructions

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Guidelines for Mandatory and Voluntary Use of ABNs

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•GAGA- - provider expects Medicare will deny the services as not reasonable and necessary and the beneficiary has signed an ABN that is on file in the medical records.

• GA also indicates that a beneficiary or their representative refused to sign an ABN and the proper documentation is on file in the medical records.

•GYGY - item or service is statutorily excluded or does not meet the definition of a Medicare benefit. The modifier GY does not require an ABN.

•GZ - GZ - item or service is expected to be denied as not reasonable and necessary and there is no ABN on file. The modifier GZ does not allow the provider to bill the beneficiary.

Check commercial carriers guidelines for ABN guidelinesCheck commercial carriers guidelines for ABN guidelines

3 ABN Modifiers

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• Always include a copy of the original EOB, and any additional documentation necessary to provide evidence for the appeal.

Medical records indicating medical necessityCurrent Clinical guidelinesMedical journal articles

General Appeal Guidelines

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• Cover letters are also effective for appeals and will “set the stage” with the claims reviewer.

Common language Don’t assume reviewer knows anything about BMM Don’t assume reviewer understands lab levels

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• If you feel that the payer has not responded to your request, don’t give up.

Did they receive it?How long is their normal “review” times?Special forms to fill out?Check their guidelines

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NCD/LCDs can be reconsidered. The NCD reconsideration process is found at: http://www.hhs.gov/dab/divisions/appellate/ncdappeals/appealsnotice.html#.Ue3nY5nD_IU

Each administrative contractor has the reconsideration process on their website.

General Medicare Appeal Guidelines

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Coding and billing do not go hand in hand

Read your commercial contracts- know expectations and administrative guidelines for your negotiated services and procedures

Ensure EVERYONE involved with the billing and coding for the office understand the False Claims Act and it’s importance

Reminders…

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Be familiar with your MAC- your LCD (local coverage determinations) and the NCD (national coverage determinations)

Codes change and are updated each year- obtain current books

Be familiar with coding books’ coding conventions and guidelines

71“It takes a village to raise a child.” Old Proverb

It takes an entire office

to get a claim coded,

filed and reimbursed

appropriately.

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Questions?

Thank you for your time and attention!

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Vanessa Lankford, CPC, CMCO, CMOM, AACE-CECAHIMA Approved ICD-10CM Trainer

Practice Management CoordinatorAmerican Association of Clinical Endocrinologists

www.aace.com(904) 353-7878 ext. 123

vlankford@aace.com