Physician Lunch-N-Learn
BIG CHANGES IN STORE FOR
PHYSICIAN E & M DOCMENTATION
Presented by: HomeTown Health
January 19, 2010
WEBINAR SPONSORED BY OPATH.NET
Agenda:
•Medicare Eliminates Consultation Codes
•Cahaba Physician Update
•State Health Benefit Plan 2010 Changes
•PECOS Provider Number Validation
•RAC Update
Medicare Eliminates
Consultation Codes
Medicare Eliminates
Consultation Codes
Officially released and documented in Change Request “CR
6740” as of January 1, 2010 “consultation” codes will be
eliminated from the Medicare fee schedule.
http://www.cms.hhs.gov/Transmittals/downloads/R1875CP.pdf
Medicare will no longer recognize or pay for services billed
with consultation codes 99241-99245 or 99251-99255.
Practices must bill for these services using regular
evaluation and management codes (CPT 99201-99205
and 99211-99215), which reimburse at a significantly
lower rate than the consultation codes.
Change Request 6740
SUBJECT: Revisions to Consultation Services Payment Policy
 I. SUMMARY OF CHANGES: In the calendar year 2010 physician
fee schedule final rule with comment period (CMS-1413-FC) CMS
budget neutrally eliminated the use of all consultation codes
(inpatient and office/outpatient codes) for various places of
service except for telehealth consultation G-codes. CMS increased
the work relative value units (RVUs) for new and established
office visits, increasing the work RVUs for initial hospital and
initial nursing facility visits, and incorporating the increased use of
these visits into our practice expense PE and malpractice
calculations. CMS also increased the incremental work RVUs for
the evaluation and management (E/M) codes that are built into
the 10-day and 90-day global surgical codes.


EFFECTIVE DATE: *January 1, 2010
IMPLEMENTATION DATE: January 4, 2010
Medicare Eliminates
Consultation Codes Cont.
According to an article in the Physician News, the key to
minimizing the financial impact of this change will be the
verification of patient insurance prior to the physician
visit. The provider must be made aware of a patient’s
Medicare coverage in advance of coding and use the
appropriate CPT code to bill for the service.
To receive proper reimbursement, providers must instruct
their staff to monitor changes in insurance coverage
carefully. Attention must be paid to the Medicare
Advantage plans that are likely to follow the Medicare
rules.
Hospital Physician Billing
Hospital Physicians who previously billed with
a consult code will now use initial hospital
codes of 99221-99223 when requested to
see a patient.
Attending physicians will append Modifier
“AI” to their initial visit so that Medicare can
differentiate between attending visits and
consulting physicians.
Nursing Home Physician Billing
Nursing home physicians who previously billed
using an inpatient consult code will now use
initial nursing home codes of 99304-99306.
The admitting or attending physician will append
the “AI” modifier to their charge.
Emergency Room Physician
Billing
Emergency Room Physicians previously billing
outpatient consults will use
ER codes 99281-99285.
These codes were previously designated for
Emergency Room Physicians only.
Office Physician Billing
In the office, physicians will use codes
99201-99215 for a new or established
patient visit in place of consults.
A new patient is a patient who has not received a
professional service from the physician or from
other physicians of the same specialty in the
same group in the past three years.
Office Physician Billing
Remember:
if you treat a patient in the hospital and then you
or any member of your group treats that patient
in your office, the patient is not considered to be
a “new patient”.
Use the following table as a guide:
Place of Service
Up to December 31,
2009
After January 1,
2010
Hospital
99251-99254
99221-99223
Nursing Home
99251-99254
99304-99306
ER
99241-99245
99281-99288
Office or outpatient
99241-99245
99201-99215
A bill was introduced in the Senate in early December to maintain the consultation codes
for an additional year. However, it is unclear at this time whether or not the bill will be
passed.

Elimination of codes
Specialty physicians currently bill Medicare differently for
consultation, which is the initial consultation of a new patient
following another physician's referral, and evaluation and
management, which is the more straightforward, face-to-face
evaluation and management of a patient's health, says Mr. Miller.
Both sets of codes reimburse for five levels of service, which are
determined by the time required for the evaluation, the
comprehensiveness of the history and exam, the complexity of the
medical decision and the severity of the medical problem. However,
the consultation codes reimburse physicians at a significantly higher
rate

http://www.beckersasc.com/coding-billing-andreimbursement/coding-billing-and-reimbursement/changes-to-oppsfinal-rule-eliminating-consultation-codes-and-the-impact-onhealthcare-providers.html
The codes are unlikely to impact primary care physicians since they
typically do not perform consults. Specialty physicians, however,
are likely to notice reduced reimbursements from these highvolume codes.
For example:
 a physician in Chicago is reimbursed $243.65 for a level 5
consultation and $161.82 for a level 5 evaluation and management
service, a nearly one-third decrease in reimbursement, according to
the Medicare Physician Fee Schedule.
 A physician in New York receives $259.19 for a level 5 consultation
versus $171.49 for a level 5 evaluation and management service, a
roughly 34 percent decrease.
A bill was introduced in the Senate in early December to maintain
the consultation codes for an additional year. However, it is unclear
at this time whether or not the bill will be passed.
The link for the article in Physician News:
http://www.physiciansnews.com/2010/01/08/medicare-eliminatesconsult-codes-what-your-practice-needs-to-prepare/
CAHABA PHYSICIAN
UPDATE
Widespread Probe Notification - J10 MAC A - GA & TN Notice of upcoming Widespread Probe Review of CPT
codes 99212, 99213 and 99214 submitted with CPT
Modifier 25 for Bill Type 13X
12/30/09
As a result of data analysis, Cahaba GBA will soon be
conducting a widespread review of CPT codes 99212, 99213
and 99214 (E/M Codes) billed with Modifier 25 (Significant,
separately identifiable evaluation and management service
by the same physician on the same day of the procedure or
other service) for Bill Type 13X.
The topic for this review will be 5017Q for Georgia providers
and 5011T for Tennessee providers.
12/30/09 Widespread Probe Notification - J10 MAC A GA & TN - Notice of upcoming Widespread Probe
Review of CPT codes 99212, 99213 and 99214
submitted with CPT Modifier 25 for Bill Type 13X
Claims meeting the parameters of this edit will be selected
across the provider community. Once selected, the claims
will be reviewed for medical necessity (e.g. compliance with
CMS' guidelines, contractor LCD's, correct billing and coding).
This will be a line level review. The data from this review will
assist us in determining our providers' educational needs.
Once completed, the results of this probe will be posted on
our web site.
Widespread Probe Review Results Notification - J10
Mac A - Georgia - Review of CPT 99291, Critical Care,
Evaluation and Management of the Critically Ill or
Injured Patient: First 30-74 Minutes, TOB 13X
Medical Review Part A has recently completed the widespread prepay probe
review of CPT 99291, Critical Care Evaluation and Management of the
Critically Ill or Injured Patient: First 30-74 Minutes, TOB 13X.
The claims were randomly selected across the provider community billing
this service that met the parameters of the edit. The edit number for
this review was 5005Q.
Based on the outcomes of this review, a prepay targeted review
will be initiated. The edit number for the targeted review will be
5001R.
Widespread Probe Review Results Notification - J10
Mac A - Georgia - Review of CPT 99291, Critical Care,
Evaluation and Management of the Critically Ill or
Injured Patient: First 30-74 Minutes, TOB 13X Cont.
Review of the claims submitted indicated that the documentation did not support
critical care services were provided as submitted on the claim by the billing of
99291.
Critical care time reported is time spent by a physician and/or hospital staff
engaged in active face-to-face critical care of a critically ill or critically injured
patient.
Critical care is defined as a physician's (or hospital staff's) direct delivery of medical
care for a critically ill or critically injured patient.
A critical illness or injury acutely impairs one or more vital organ systems such that
there is a high probability of imminent or life threatening deterioration in the
patient's condition.
Widespread Probe Review Results Notification - J10
Mac A - Georgia - Review of CPT 99291, Critical Care,
Evaluation and Management of the Critically Ill or
Injured Patient: First 30-74 Minutes, TOB 13X Cont.
Critical care involves high complexity decision making to assess, manipulate, and
support vital systems functions to treat single, or multiple , vital organ system
failure; and/or to prevent further life threatening deterioration of the patient
condition.
Examples of vital organ system failure include (but are not limited to); central
nervous system failure; circulatory failure; shock; renal, hepatic, metabolic,
and/or respiratory failure.
Although it typically requires interpretation of multiple physiologic parameters
and/or application of advanced technology(s), critical care may be provided in
life threatening situation when these elements are not present.
Widespread Probe Review Results Notification - J10
Mac A - Georgia - Review of CPT 99291, Critical Care,
Evaluation and Management of the Critically Ill or
Injured Patient: First 30-74 Minutes, TOB 13X Cont.
When performed on the day a physician bills for critical care, the
following services are included in the critical care service, and
should not be reported separately:
 The interpretation of cardiac output measurements (CPT 93561, 93562)
 Chest x-rays, professional component (CPT 71010, 71015, 71020)
 Blood draw for specimen (CPT 36415)
 Blood gases (82800-82810), and information data stored in
computers(e.g.,ECG's, blood pressures, hematologic data - CPT 99090)
 Gastric intubation (CPT 43852, 91105)
 Pulse oximetry (CPT 94760, 94761, 94762)
 Temporary transcutaneous pacing (CPT 92953)
 Ventilator management (CPT 94002-94004, 94660, 94662)
 Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)
Widespread Probe Review Results Notification - J10
Mac A - Georgia - Review of CPT 99291, Critical Care,
Evaluation and Management of the Critically Ill or
Injured Patient: First 30-74 Minutes, TOB 13X Cont.
No other procedure codes are bundled into the critical care services.
Therefore, other medically necessary procedure codes may be billed
separately.
Documentation in some reviews did not support the time billed for 30-74
minutes as is required for 99291. The records in some reviews
indicated that the patient had arrived on full life support and was
pronounced dead soon after arrival.
 The medical review decisions were based on the following:
 Current Procedural Terminology Manual
 Medicare Claims Processing Manual, Chapter 12, Section 30.6.12
 CR #5993-Eff. 7/01/2008
Page last updated: October 29, 2009
https://www.cahabagba.com/part_a/whats_new/20091028_ga_cpt99291.htm
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X
Medical Review Part A has recently completed the widespread targeted
review of CPT 97597 Wound Debridement; Total Wound(s) Surface
Area < or+ 20 Centimeters for Bill Type 13X
and
CPT 97598 for Wound Debridement; Total Wound(s) Surface > 20
Centimeters for Bill Type 13X.
The claims were randomly selected across the provider community billing
this service that met the parameters of the edit. The edit number for
this review was 5004Q.
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X
As a result of the analysis of errors related to the widespread probe review
Cahaba GBA® will be initiating an ongoing widespread targeted review
for CPT Code 97597 and CPT Code 97598.
The topic code for this ongoing review will be 5003R, and will select claims
with CPT codes 97597 and 97598. Claims will be selected across the
provider community billing these services that meet the parameters of
the edit. Once selected, the claims will be reviewed for medical
necessity (e.g. compliance with CMS' guidelines, contractor LCDs,
correct billing and coding).
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X Cont.
A summary of the denial codes for this claim indicates denials
due to the following reasons:





53714-Absent physician certification/re-certification
54155-Inadequate medical justification submitted
55520-Inadequate medical documentation submitted
53603-The medical record did not verify that the services describe
by the HCPCS code was provided
56900-Due to the lack of requested documentation, services have
been deemed not medically necessary
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X Cont.
The following issues were identified by medical review that led to denial
for services were follows:
 There was no documentation of wound measurements on the treatment notes
or progress notes.
 Debridement charged, but documentation states the wound bed is clean with
100% granulation tissue prior to debridement; no documentation of tissue to be
debrided.
 Billing whirlpool (97022) on the same date as debridement (97597 or 97598).
Whirlpool is not separately billable; is included in 97597/97598.
 97597/97598 is per session and is not billable in multiple units per visit. The
use of GP modifier 59 to allow billing of more than one 97597/97598 should
only be done if the patient is seen for 2 separate sessions on the same date;
not used to allow 97597-97598 to be billed greater that one for the same
session.
 No documentation of method of selective debridement.
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X Cont.
Issues Cont.







Evaluations (97001) do not meet the criteria as defined in the LCD for
billing 97001; only a wound assessment is performed. Wound assessment is
part of the 97597/97598 code and should not be billed separately as 97001
unless a complete evaluation as defined in the LCD is performed.
Documentation does not support that selective debridement was
performed. Documentation indicates wound cleaning and dressing change,
non-excisional debridement, scrubbed wound with 4X4, or non selective
debridement.
No physician order or plan of care signed by the physician for the registered
nurse to provide selective debridement.
No signed plan of care to cover services performed by the physical therapist
or updated plan of care for the dates of service being reviewed.
No initial evaluations and/or wound assessments submitted.
Wound clinic services and no physician orders submitted for selective
debridement.
Documentation states wound closed, but selective debridement was billed.
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X Cont.
There were 25 denials due to the lack of timely submission of requested
documentation, as indicated by denial reason code 56900.
According to the Medicare Program Integrity Manual, PUB 100-8, Chapter
3, § 3.4.1.2, if a coverage or coding determination cannot be made
based upon the information on the claim, the Fiscal Intermediary (FI)
may solicit additional documentation from the provider by issuing an
Additional Documentation Request (ADR) and must notify the provider
of the 30 day time-period to respond.
ADR must outline the specific documentation elements needed to make a
coverage or coding determination. If information is requested from the
billing provider and no response is received within 45 days after the
date of the request, then the claim must be denied. All providers are
expected to comply with the timely submission of requested
documentation as required by CMS, should claims be selected for
medical review.
Widespread Probe Review Results Notification - GA Part
A - Notice to Georgia providers of review results from
Widespread Probe Review of CPT 97597 & 97598,
Revenue code 0420 for Bill Type 13X Cont.
The Intermediary again reminds the provider community of the
importance of thorough documentation in the medical record to
support CMS requirements for appropriate billing of services. Due to
the lack of compliance with these coverage guidelines, Alabama Part A
Medical Review will conduct a corrective action widespread pre-pay
review of CPT Codes 97597 and/or 97598. Also, providers identified
through data analysis as driving this aberrancy may warrant provider
specific medical review.
Please review the LCD L1505 for further clarification of issues pertaining to
Debridement Services.
https://www.cahabagba.com/part_a/whats_new/20091202_cpt97597.htm
State Health Benefit Plan
2010 Changes
PECOS Provider Number
Validation
ALL Provider Number/NPI’s Must be ReValidated in PECOS SYSTEM prior to April
1 if it hasn’t been revalidated within the
last 3 years
IF NOT – All Claims including this NPI
Number will be rejected
http://www.cms.hhs.gov/MedicareProviderSupEnroll/
04_InternetbasedPECOS.asp
RAC Update
NEW ISSUE POSTED
on CMS RAC webpage

Issue Name: Barium Swallow Studies Units Billed Description: Barium
Swallow Studies can only be billed with a unit of (1) per patient per date of
service.




Provider Type Affected: Physician (Carrier) / Outpatient Hospital
Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas,
Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North
Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin
Islands, Virginia (Physician/Carrier Only), West Virginia (Physician/Carrier
Only)
MUE’s
Current ISSUES POSTED
on CMS RAC webpage



Issue Name: Blood Transfusions Description: CPT codes 36430, 36440,
36450, and 36455 (excluding claims with any modifiers) should be billed as
one (1) per session, regardless of the number of units transfused on that
date of service.
Provider Types Affected: Outpatient Hospital and Physician
Date of Service: 10/01/2007 - Open States Affected: Alabama, Florida,
Georgia, South Carolina Additional Information: Additional information can
be found in the following manuals/publications:



Federal Register, Volume 67, No.212, 66868
Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001,
page 1
CMS Pub 100-04, Ch. 4, § 231.8
Current ISSUES POSTED
on CMS RAC webpage

Issue Name: IV Hydration Therapy Description: Based on the definition of
CPT 90760 (excluding claims modifier-59 ), the maximum number of units
should be one (1) per patient per date of service. Beginning 1.1.09, code
90760 was replaced with code 96360.



Provider Types Affected: Outpatient Hospital and Physician.
Date of Service: 10/01/2007 - Open States Affected: Alabama, Florida,
Georgia, South Carolina Additional Information: Additional information can
be found in the following manuals/publications:




CMS Pub 100-4 Ch. 12, pages 31-32
CMS Pub 100-20, Transmittal 419, page 7
MLN Matters, MM6349 R/T RC Release Date 12.19.08, page 4
Current New ISSUED POSTED
on CMS RAC webpage

Issue Name: Untimed Codes Description: CPT Codes (excluding modifiers
KX, and 59) where the procedure is not defined by a specific timeframe
(untimed codes), the provider should enter a one (1) in the units billed
column per date of service.






Provider Types Affected: Outpatient Hospital and Physician
Date of Service: 10/01/2007 - Open States Affected: Alabama, Florida,
Georgia, North Carolina, South Carolina Additional Information: Additional
information can be found in the following manuals/publications:
CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11
CMS Pub 100-04, Ch. 5, § 20.2
New FAQ on CMS RAC webpage
If the incumbent Part B carrier is awarded the MAC contract, is there a Recovery Audit
Contractor (RAC) “Blackout” on Part B RAC activity, Part A RAC activity, both, or
neither?
Answer
No, in this situation there will not be a blackout period if the Part B carrier is awarded a
MAC contract for the same jurisdictions (states) in which they previously served as a
Medicare Carrier. However, in this example there would be a blackout period for Part
A activity since the Part A work was not previously performed by the winning MAC
for the jurisdiction.
Will there be a Recovery Audit Contractor (RAC) blackout if a subcontractor to the MAC
is the incumbent Part A FI or Part B carrier?
Answer
No, there will not be a blackout period if the Part A FI or Part B carrier has been
awarded a MAC contract for the same jurisdictions (states) in which they previously
served as a Medicare Affiliated Contractor.
This FREE update brought to
you today by OPATH.NET
Visit www.OPATH.net to check out the online education
available 24/7 for Physician Practice Managers and Staff
For more information on signing up for OPATH.net
Contact Kathy Whitmire at
kfw@windstream.net