1. Code for Documentation!Audit for Compliance! Richard J Hamburger MD Professor Emeritus of Medicine Indiana University Indianapolis IN Debra H. Lawson, CPC, PCS Nephrology Billing & ManagementServices, LLC Rogersville, TN

2. Objectives interaction requested

Session I

Review Changes in codes

• ESRD

• Infusion

Consultation v. referral

• New patient v. your patient

• Hospitalist care

Session II

Discharge day

Hospital dialysis

Intensive care

• Definition & rules

• Tips

Compliance Assessment

3. ESRD Codes Where are we?

Previous CPT family (1995-2003)

• 90918-90925

G-code living (2004-2008)

• G0308-G0327

The new times (2009- )

• 90951-90970

4. End Stage Renal Disease Services(ESRD)

CPT codes 90918 90925 have been deleted and new codes are under a new section entitled End Stage Renal Disease Services

G codes for ESRD disappeared

CPT codes 90951 90970 have been added with new code descriptors

5. What are we trying to capture?

Physician work for patients on dialysis

Excluded:

• Inpatient services

• E&M services that cannot be furnished on dialysis (non-renal related)

• Non-ESRD dialysis services performed in an outpatient setting

6. Approach to the family

CPT groupings by age

Youngest to oldest

In center code values first

Home dialysis values to follow

Daily visit code values to conclude

7. End-Stage Renal Disease Services

Codes 90951-90962 are reportedonceper month to distinguish age-specific services related to the patient's end-stage renal disease (ESRD) performed in an outpatient setting with three levels of service based on the number of face-to-face visits. ESRD-related physician services include establishment of a dialyzing cycle, outpatient evaluation and management of the dialysis visits, telephone calls, and patient management during the dialysis provided during a full month. In the circumstances where the patient has had a complete assessment visit during the month and services are provided over a period of less than a month, 90951-90962 may be used according to the number of visits performed.

8. End-Stage Renal Disease Services

Evaluation and Management services unrelated to ESRD services that cannot be performed during the dialysis session may be reported separately. Codes 90967-90970 are reported to distinguish age-specific services for end-stage renal disease (ESRD) services for less than a full month of service, per day, for services provided under the following circumstances: home dialysis patients less than a full month, transient patients, partial month where there was one or more face-to-face visits without the complete assessment, the patient was hospitalized before a complete assessment was furnished, dialysis was stopped due to recovery or death, or the patient received a kidney transplant. For reporting purposes, each month is considered 30 days.

9. End-Stage Renal Disease Services

90960End-stage renal disease (ESRD)

related services monthly, for

patients 20 years of age and

older; with 4 or more face-to-face

physician visits per month

90961with 2-3 face-to-face physician

visits per month

90962with 1 face-to-face physician

visit per month

10. Adult In Center codes:> 20 y.o.

G codeValueCPT 2009Value

G0317 5.09 90960 5.18

G0318 4.24 90961 4.26

G0323 3.39 90962 3.15

11. End-Stage Renal Disease Services

90966 End-stage renal disease (ESRD)

related services for home dialysis

per full month, for patients 20

years of age and older

G codeValueCPT Value

G0323 4.24 90966 4.26

12. Pediatric In Center codes: 1hr

Therapeutic, prophylactic or diagnostic IV infusion of substances or drugs 96365-96376

44. CONSULTVREFERRAL CORRECT CODING CAN MEAN $$$$ INCORRECT CODING. 45. CONSULTATION

At the request of a referring physician or other appropriate source foropinion or advice

Requires evaluation and/or management of aspecificproblem

Requires written communication to the requesting physician or other appropriate source

46. CONSULTATION

Documentation must properly reflect work done according to CPT description of consultation (key and contributing components)

47. Concurrent Care and Transfer of Care Currently accepted for CPT 2010

Concurrent care is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required.

48. Concurrent Care and Transfer of Care Currently accepted for CPT 2010

Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation, but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.

49. Concurrent Care and Transfer of Care Currently accepted for CPT 2010

Transfer of care is the process whereby a physician who is providing management for some/all of a patients problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility, and who from the initial encounter is not providing consultative services.The physician transferring care is then no longer providing care for these problems, though may continue providing care for other conditions when appropriate

50. Concurrent Care and Transfer of Care Currently accepted for CPT 2010

A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition/problem or to determine whether to accept responsibility for ongoing management of the patients entire care or for the care of a specific condition/problem

51. Concurrent Care and Transfer of Care Currently accepted for CPT 2010

The written or verbal request forconsultation may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source.

The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source.

52. CONSULTATION

The service meets the requirement for a consult when:

• The service is not simply a continuation of care by a consultant for an established clinical problem of an established patient

• • For example, treatment in a different clinical setting such as an E/M service for continuation of previously established outpatient care in the inpatient setting for patients admitted by another physician for a separate reason

53. CONSULTATION

The opinion rendered is of such a nature that it will be used by, and in some manner will affect, the requesting physicians own management of, or decision-making about, the patient.

When the referring physician will not be involved in any subsequent decision-making about the problem for which the referral has been made, the service should not be coded as a consultation.

54. NON-PHYSICIAN PRACTITIONERS & CONSULTS

Initial consults in the outpatient setting must be performed entirely by the physician

Non-physician practitioners cannot perform any portion of an initial consult and bill the consult under the physicians provider number

Incident to requires non-physician practitioners services to follow the treatment plan of the physician and the physician must continue to have ongoing care and update with the patient

55. NON-PHYSICIAN PRACTITIONERS & CONSULTS

Consults performed in the inpatient setting cannot be shared services between the non-physician practitioner and the physician

If the non-physician practitioner is involved, the consult must be billed under the NPPs provider number

56. PRE-OPERATIVE CLEARANCE

Covered Medicare service

Record must demonstrate preoperative medical evaluation is reasonable and necessary given the patients medical condition and the nature of the proposed surgical procedure

Opinion of the consultant will be used by the requesting surgeon in perioperative management of the patient

57. PRE-OPERATIVE CLEARANCE

The E/M service documented mustnotconstitute any of the following:

• E/M service provided to fulfill the mandatory preoperative or preadmission H&P (part of the operating surgeons global)

• Substitute for proper preoperative clearance by surgeon

• E/M is a continuation of outpatient services which would not affect the operating surgeons decision-making regarding the patient

58. WHAT IS NOT A CONSULT

Initiated by patient and/or patients family

If initiated at the request of a third party payer visit is reported as a consult

• Requires use of Modifier -32, mandated services (not recognized by Medicare)

• Requires report back to third party payer

59. REFERRAL

Physician refers a patient to another physician for the management of a particular condition concurrent care

First visit is reported as new patient visit

Referring physician relinquishes care for that particular condition to the new physician

60. CONSULTATION CODES

99241-99245 Office or Outpatient Consult

99251-99255 Inpatient Consult Codes

99251-99255 Initial Consults in the Skilled Nursing Facility/Nursing Facility

61. USE OF HOSPITALISTS

Many facilities in an effort to retain monies within the hospital system have added hospitalists to their staff

Facilities are encouraging associated providers to utilize hospitalists for admitting their patients

Many physicians are utilizing hospitalists because it eliminates the extra work of an admission

62. USE OF HOSPITALISTS

As a substitute for this quality of life issue for the nephrologist using hospitalists there is a economic issue

When you initiate a consultby requesting a hospitalist admit, it is difficult to meet the criteria for a consultation thus making the initial encounter in the inpatient setting subsequent care or dialysis

63. USE OF HOSPITALISTS

There are arguments for using hospitalists, including hospital relations

One must weigh the positives and negatives to determine if this is a choice the individual nephrologist or group makes

64. CONSULT TIDBITS

Inpatient consultation may only be reported once per consultant per facility admission

If the consultant continues to care for the patient following the initial consultation, report additional visits using established patient visit codes

Reason for the consultation must be documented in the medical record along with the name of the requesting provider

65. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Consultation before coding a consult ask these questions about the service if the answer is NO to any, do not report as a consult

• Did you receive a request for an opinion from another provider?

• Does your documentation of the service clearly demonstrate who made the request and the nature of the opinion requested?

66. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Consults cont.

• Have you provided a written report of your opinion/advice to the requesting physician?

• Though the requesting physician may have asked for a consultation should the service provided be reported as a consult?

• • Will your opinion be used by, and in some manner effect the requesting physicians own management of the patient or is it a transfer of care for a particular problem?

67. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Consults cont.

• • Will the requesting physician be involved in subsequent decision making about the problem for which the request has been made?

• • For pre-operative consultations, is the service requested specifically for pre-operative clearance that is medically necessary considering the patients condition and the procedure planned?

• • Is the pre-operative consultation a substitute for the mandatory H&P to be provided by the operating surgeon?

• • • THIS IS NOT A SEPARATELY BILLABLE SERVICE

68. DISCHARGEMANAGEMENT SERVICES 69. DISCHARGE CRITERIA

The hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.

70. DISCHARGE CRITERIA

**NEW** - CHANGE REQUEST 5794 TRANSMITTAL 1460 Effective Date April 1, 2008 Implementation Date April 7, 2008

Discharge services are considered a face-to-face service

Billable only by the attending physician

Discharge day services by other physicians are billing used 99231-99233

Bill on the day the visit by the physician is done even if the patient is discharged on a different calendar day

71. DISCHARGE CRITERIA

Medicare pays for the paperwork of patient discharge as part of the pre- and post-work of the E&M service

Medicare does not pay for a subsequent hospital visit (99231-99233) on the same day as a discharge

Medicare pays for the hospital discharge in addition to a nursing home admit when billed by the same physician on the same date of service

• • • • Change request 5794,transmittal 1460

72. DISCHARGE CRITERIA

Medicare pays only for the physician who personally performs the pronouncement of death for the discharge day management service.The date of pronouncement shall reflect the calendar date of service on the day it was performed even though the paperwork is delayed.

This can be the attending or any other physician

These changes are reflected by CR 5794, Transmittal 1460

73. DISCHARGE MANAGEMENT

99238 Discharge management 30 minutes or less

99239 Discharge management over 30 minutes

Since time driven code requires documentation of services rendered and time spent performing services

If time is not documented, 99238 is billed

74. NEPHROLOGYSPECIFICCPTCODING 75. INPATIENT DIALYSIS CODES

90935- Single physician evaluation of hemodialysis

90937- Multiple physician evaluation of hemodialysis

90945- Single physician evaluation of continuous forms of dialysis

90947- Multiple physician evaluation of continuous forms of dialysis

• Includes E&M services rendered on the same day except admission, consultation or discharge services

76. INPATIENT DIALYSIS CODES

To bill the physician must meet the following:

Be presentduringthe dialysis treatment

Documentation must reflect presence during the treatment

The need for repeated visit should be noted in the patients chart.The note should include the problem or anticipated problem which required the physicians repeat evaluation

77. INPATIENT DIALYSIS CODES

Four E/M services that can be billed on the same day as dialysis services

Hospital admission

Hospital discharge

Inpatient consultation

Critical Care

• Most carriers require the use of a -25 modifier on the E/M code on the same day as a procedure

78. EXAMPLE:DIALYSIS NOTE 90935

Date: 20 February2009, 1225 h

Procedure: Patient seen on Hemodialysis

Location:Surgical intensive care unit

Physician: Paul Nephron, MD

Indication: Acute renal failure, glomerulonephritis

Rx: Qb=350, Qd=800, Td=255 min, dialyzer=F8,

dialysate=2 K, 2.5 Ca, 35 HCO 3 , target= -3.5 L

• • • Transfuse 2 units PRBCs, 25 g SPA

• • • Anticoagulation=2000 units bolus, 1000 unitscontinuous infusion

• • • Target: ACT 1.5-2X baseline

Access: Right femoral vein double lumen catheter

Comments: BP 165/98, P 88, wt 154 lb

• • • Chest: bibasilar rales; Cor: S1 S2 RR

• • • Exts: 5 mm bilateral pitting into thighs

• • • Hb 7.8, K 6.3, Alb 2.2

Sign and time stamp note

79. EXAMPLE:JUSTIFICATION 90937

20 February 2009, 1445 h

Chest pain

• Seen again on dialysis

• • Pleuritic chest pain 2 h into treatment

• • 1.5 L fluid removed, SPA given, PRBCs pending

• • NTG SL given x 1 with minimal relief in 10 min

• BP 108/64, P 105 reg

• • Chest: bibasilar rales, left anterior chest wall pain reproduced with palpation

• • Cor S1, S2, no rubs; Exts: 5 mm edema bilaterally

• • ECG: no interval changes

• • Chest pain, most likely non-cardiac in origin

• Continue dialysis

• • Transfuse 2 units PRBCs as planned

• Sign and time stamp note

80. 90937 vs CRITICAL CARE WHEN IS EACH APPROPRIATE? 81. CODING FOR CRITICAL CARE 82. 99291

Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

83. 99292

Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes

84. CPT DEFINITIONCRITICAL ILLNESS OR INJURY

A critical illness or injury acutely impairs one or more vital organ system(s) such that there is a high probability of imminent or life threatening deterioration in the patients condition.

85. CPT DEFINITIONCRITICAL CARE SERVICES

Critical care is thedirect deliveryby a physician(s) of medical care for a critically ill or injured patient.

Involves decision making of high complexity to assess, manipulate, and support system function(s), to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patients condition.

86. CPT DEFINITIONCRITICAL CARE SERVICES

Examples of Vital Organ System Failure

Central nervous system failure

Shock

Circulatory failure

Renal failure

Hepatic failure

Respiratory failure

Metabolic failure

87. CPT DEFINITIONCRITICAL CARE SERVICES

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patients condition continues to require the level of physician attention as previously described.

88. WHERE CRITICAL CAREIS PROVIDED

Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.

89. CRITICAL CARETREATMENT CRITERION

Critical care services require directpersonalmanagement by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician.

Failure to provide these interventions on an urgent basis would result in life threatening deterioration in the patients condition.

90. CRITICAL CAREFULL ATTENTION REQUIREMENT

Critical care is used to report the total duration of time spent by a physician providing critical care services to a critically ill or injured patient, even if the time spent by the physician on that date is not continuous.For the time spent, the physician must devote his or herfullattention to the patient

91. WHERE IS CRITICAL CARE PROVIDED

Time spent with the individual patientmustbe recorded in the patients record.

Time spent can be reported if spent is at the bedside or on the unit or floor, i.e.. Coordinating care, butcannotbe in caring for another patient.

Can include time spent with family, etc. when the patient cannot make decisions for self.

92. CRITICAL CARE DOCUMENTIONFOR MEDICAL REVIEW

Must indicate full attention provided

Since time based, must contain documentation of total time involved

Time involved with family to gain pertinent history or make decisions must be documented

Telephone calls to family members to be considered must meet same criteria as face-to-face

93. SERVICESNOTINCLUDED IN CRITICAL CARE TIME

Time spent providing services not bundled into critical care time such as dialysis or access placement are not included

Services rendered earlier in the day prior to the patients need for critical care.This service can be reported separately, but documentation needs to be sent with the claim and a modifier(-25) needs to be appended to this service.CR 5792

Time spent updating patients family about status not meeting previous criteria regardless of how lengthy

94. CRITICAL CARE & DIALYSIS

Dialysis (90935, 90937, 90945, 90947) is not included in Critical Care time

Make sure a separate note is made for dialysis and all the criteria for billing dialysis are metphysical presence during the treatment

Append a -25 modifier to the Critical Care code

95. CRITICAL CARE TIDBITS

99291 is used to report first hour (30-74 minutes) of critical care

99292 is used to report each additional 30 minutes

99292 is used to report final 15-30 minutes of critical care

Critical care of less than 30 minutes is reported using appropriate E/M code

Only one physician may bill for a given hour of critical care even if more than one physician is providing care

96. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Critical Care Before coding for critical care, ask the following questions.If the answer is NO do not report as critical care.

• Does the record documented show work performed to be more intense than work of other E/M services of the same time duration?

• Does the record demonstrate the patient hasacuteimpairment of one or more vital organ systems and has a high probability ofimminentorlife-threateningdeterioration?

97. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Critical Care cont.

• Does the documentation demonstrate all of the following?

• • Direct personal management.

• • Frequent personal assessment and manipulation (not just the general once-a-day visit).

• • High-complexity decision-making to assess, manipulate and support vital system function(s) to treat single or multiple organ system failure or to prevent further deterioration.

98. TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

Critical Care cont.

• • Interventions of a nature that failure to initiate these interventions on an urgent basis would likely result in sudden clinically significant or life-threatening deterioration in the patients condition.

• What about the time spent providing critical care?

• • Is specifically recorded?

• • Is it reasonable considering the documented work provided?

• • Does it exclude time spent performing procedures separately billable?

• • If it includes time spent with family, was the family members operating as a surrogate decision-maker because the patient was unable to make decisions?

99. ComplianceAssessment 100. Compliance Assessment

Who

What

Where

When

Why

101. Compliance Assessment

Why

To get paid for your work you must document

Audit and review within a practice produces better coding and billing

PQRI will be replaced by deductions so be prepared

102. 103. 2009 Nephrology Specific PQRI Measures MEASURE NUMBER MEASURE DESCRIPTION REPORTING OPTIONS END STAGE RENAL DISEASE (ESRD) 79 Influenza Immunization in Patients with ESRD Claims, Registry 81 Plan of Care for Inadequate HemodialysisRegistry 82 Plan of care for Inadequate Peritoneal Dialysis Registry CHRONIC KIDNEY DISEASE (CKD) 121 Laboratory Testing (calcium, phosphorus, intact parathyroid hormone (iPTH) and lipid profile) Claims, measures group (MG), and Registry 122 Blood Pressure Management Claims, MG, and Registry 123 Plan of Care for Elevated Hemoglobin for Patients Receiving ESA Therapy Claims, MG, and Registry 135 Influenza Immunization in Patients with CKD Claims, MG, and Registry 153 Referral for AV Fistula Claims, MG, and Registry 104. 2009 Claims Based Reporting

Same reporting requirements from 2007 and 2008 programs

• Must report at least 3 quality measures on at least 80% of claims where PQRI measures could be reported.

• Validation through denominator coding.Applicable cases defined by CPT codes included in the denominator of each PQRI measure.

• • ESRD PQRI measures denominator codes include all MCP codes as well as inpatient dialysis codes

• • CKD PQRI measures denominator coding includes E/M codes

• • Diabetes PQRI measures denominator coding includes E/M codes as well as diabetes self management codes

Claims must contain a line-item ICD-9 diagnosis code accompanied by a specific CPT patient encounter codealong with PQRI quality data codes (QDCs )

105. 03 170903 17 091199213150 0012345678903 170903 17 09113278F10 00123456789585.5 03 170903 17 09113281F10 00123456789Make sure that diagnosis is included in the PQRI measure specifications Each PQRI measure must have individual NPI # PQRI claims MUST contain a service (CPT) code that is included in the PQRI measure denominator 03 170903 17 09114171F10 0012345678903 170903 17 09114037F10 00123456789 106. PQRI and eRx resources available on RPAs website

www.renalmd.org/pqri

• Contains nephrology-specific information on PQRI and eRx incentive programs

• Provides information

107. Compliance Assessment

What

Hospital records v billing

Office records v billing

Dialysis services v billing

Receipts v billing

108. BILLING FORERYTHROPOIETIC STIMULATING AGENTS 109. CAUTION !

POLICIES CHANGE QUICKLY!!

Please review your own carriers LCD on a monthly basis.

Also review the NCD regularly.

Knowledge in this arena is vital.

An ounce of prevention.

110.

Pretreatment HCT Level of less than 30

Creatinine of 3.0 or greaterOR

Documented renal insufficiency (stage 3-5)

Patient s current weight in kilograms

Date of lab (within 7 days - this may vary by location)

Please understand this is an example & not intended to be taken as policy!

INITIALESA(Epoetin Alfa &Darbepoetin Alfa) ADMINISTRATIONEXAMPLE GUIDELINES 111. FOLLOW-UP ESA(Epoetin Alfa &Darbepoetin Alfa) ADMINISTRATIONEXAMPLE GUIDELINES

Current HCT level to max of 36 or multiply of Hgb x 3

Date of Laboratory Data (within the last 30 days)

ICD-9 code appropriate for state

• • • Please understand this is an example & notintended to be taken as policy!

112. COMPLETING HCFA 1500 Form

Diagnosis codes

• 285.21 Anemia in CKD & stage of CKD if required

Dates of service

HCPCS code: J0885 (Procrit); J0881(Aranesp)

Units administeredper 1000 units

Other data as required

• Intermediary/carrier specific

• Hct or Hb, SCr with date, weight in kg, exceptions requests (altitude, comorbid condition), EJ modifier

113. DRUG CODES

J0881 Darbepoetin alfa, 1 mcg (non-ESRD)

J0882 Darbepoetin alfa, 1 mcg (ESRD use)

J0885 Epoetin alfa, 1000 units (non-ESRD)

J0886 Epoetin alfa, 1000 units (ESRD use)

114. BILLING FORADMINISTRATION OFESA

Drug and administration is covered incident to physician service

If the purpose of the visit is for an injection, use 96372 for the subcutaneous administration of either Procrit or Aranesp

99211 is only used when another service, not protocol for the injection, is provided

115. BILLING FORADMINISTRATION OFESA

When the drug is administered incident to a physicians visit, bill the appropriate level of E&M for the physician visit with a -25 modifier (CCI edit effective 10/1/05), the administration fee 96372 and the drug.

REMEMBER :The provider must be physically present in the suite when the injection is given to bill for the administration or the drug

116. CHANGES IN BILLING FOR ESA

Effective January 1, 2008

Effective for all non-ESRD claims with J0881 and J0885

EA : ESA, anemia, chemo-induced

EB : ESA, anemia, radio-induced

EC : ESA, anemia, non-chemo/radio induced

Without modifier will deny w/MA130 (no appeal rights submit new claim)

117. CHANGES IN BILLING FOR ESA

Test results are reported in Item 19 of the CMS 1500

For electronic claims (837P) report H/H readings in Loop 2400 MEA segment

MEA01=TR (test results), MEA02=R1 (hemoglobin) R2 (hematocrit), and the most recent result (3-digits)

Ex: 10.5 hgb (TR/R1/10.5)