January 2014 Jean C. Russell, MS, RHIT [email protected]@epochhealth.com Richard...

January 2014

Jean C. Russell, MS, RHIT [email protected]

Richard Cooley, BA, CCS [email protected]

Matthew H. Lawney MSPT, MBA, CHC, [email protected]

518-430-1144

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Agenda• Visit Codes (E/M Services)

• ED E/M Changes• Clinic E/M Changes

• Professional/Technical Implications• Pricing Implications

• Observation Changes• Proposed changes for Provider-Based

Reporting• Incident to Guideline Changes

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Proposed ChangesCMS proposed to replace the current five ED E/M

visits for type A and type B ED with a single one for each type99281-99285G0380-G0384This proposal was NOT accepted in the final rule

CMS also proposed to replace the current ten technical clinic E/M visits with a single codeThis proposal WAS adopted

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ED E/M ProposalCMS did not adopt a single G code for reporting ED

E/MCommenters felt the range of services provided in the ED

varies too significantly to reduce all visits to the single level

CMS decided to not make any changesThey are continuing to investigate

No change to the codesNo change to split billingNo change to requirements for technical E/M guidelines

for the ED

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Clinic Visit E/M CodesNew Clinic E/M

99201 – New Pt Lvl 199202 – New Pt Lvl 299203 – New Pt Lvl 399204 – New Pt Lvl 499205 – New Pt Lvl 5

Established Clinic E/M

99211 – Est Pt Lvl 199212 – Est Pt Lvl 299213 – Est Pt Lvl 399214 – Est Pt Lvl 499215 – Est Pt Lvl 5

Primary service performed and reported in a clinic is a medical visit

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E/M Clinic Visit Split BillingMedicare expects visits to a hospital based clinic

with a hospital based “physician” to be split billedPrior to January 1, 2013, hospitals would report

an E/M professionally based on CMS/CPT guidelines (either 1995 or 1997)

And an E/M technically based on hospital developed technical clinic E/M guidelines

Professional Bill (POS 22)99214

Technical Bill99212

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Clinic E/M ChangeEffective January 1, 2014 there is only one code

reported technically for clinic visits to a hospital-based clinic:G0463 - Hospital outpatient clinic visit for

assessment and management of a patientThis code replaces all of the clinic E/M codes

reported technically (99201-99205 and 99211-99215)

No change to the professional reporting rules and codes

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Summary of the Clinic Change

All clinic visits billed technically to Medicare will be reported with the same code (G0463) regardless of the complexity / duration of the visit

Beneficiary co-payment for technical component alone is close to $40 (national unadjusted); 40% of the total

There is no longer a differentiation technically between “new” and “established” patient reported codes

The professional clinic E/M’s have not changed

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Impact of the Clinic ChangeCMS has acknowledged the challenges faced by

hospital for developing guidelines for determining the appropriate visit levelNo longer necessary to develop Medicare

technical clinic E/M guidelinesED guidelines are still required

Other payers (e.g., Medicaid DOH and OMH) that are billed technically will expect the 99201-99215 codes until we are notified otherwise

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Charging SuggestionsSuggest hospitals keep the usual ten clinic E/M levels

with their charges varying by clinic E/M (i.e., 99201-99205 and 99211-99215) and then map these variable charges to the single G0463 for Medicare and (most likely) Medicare HMOsCharges may not be greater than Medicare APC

payment for the lower level visits (e.g., 99211)Should all payers be charged the same?

Issue – Medicare has a claim suspension edit in some cases when payment exceeds submitted charges

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Telephone/Internet Assessment and Management

New E/M codes for 2014Not paid under OPPS or under MPFS99446, Inter-professional telephone/Internet

assessment/management service provided by a consultative physician includes verbal and written report to the patient's treating/requesting physician; 5-10 minutes of medical consultative discussion/ review99447 … 11-20 minutes99448 … 21-30 minutes99449 … 31 minutes or more

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Telephone/Internet Assessment and Management

Used when face-to-face contract may not be timely or feasible

Not used when the patient has been transferred to the consulting doctor before the assessment

May include review of medical records, diagnostic tests, …

Majority of the service time (more than 50%) must be devoted to the actual verbal/internet discussion

Single code for cumulative timeRequest for consult must be documented

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Hypothermia Tx 99481, Total body systemic hypothermia for critically

ill neonate (per day) (List separately in addition to primary code)

99482, Selective head hypothermia in critically ill neonate per day (List separately in addition to primary code)

Add-on codes to 99291-99292, critical care, or 99468-99469, neonate IP critical care

Unconditionally packaged (SI N) under OPPS and not paid under the MPFS

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ObservationPaid as a composite under APCs (APC status

Indicator Q3)Two composites in 2013 – 8002 and 8003Requires at least 8 hours (units of 8)With a high level E/M code reported the day before

or day of observationWithout a surgical code reported the day before or

day of observation

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Observation Changes for 2014

Significant increase in packaged services (e.g., lab and stress tests)

Reduction of clinic E/M codes to a single G code (G0463)

Required changes to observation composites

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Extended Assessment and Management Composite (EAM)

In 2013 there were two composite EAMs – 8002 and 8003

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G0378 (8 or more units)Revenue code 762 (observation)Reported with:

G0379 (direct referral) on the same date of service, or99205 / 99215 (level V clinic visit) on the same date or day

before

Reported without a surgical (Status T) procedure on the same day or day before

National APC Rate (2013) = $440.70No diagnosis requirement

Level I Extended Assessment and Management - APC 8002

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G0378 (8 or more units)Revenue code 762 (observation)Reported with:

99284 / 99285 (high-level ED visit), or99291 (critical care), orG0384 (high level Type B ED visit)On the same day or day before the observation


National APC Rate (2013) = $798.47No diagnosis requirement

Level II Extended Assessment and Management APC 8003

High Level E/M

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Extended Assessment and Management Composite (EAM)

Effective 1/1/2014 there will be only one composite EAM – 8009G0378 (8 or more units), revenue code 762

(observation) with no diagnosis requirementReported with an E/M service:

99284 / 99285 (high-level ED visit) 99291 (critical care) G0384 (high level Type B ED visit) G0463 (clinic E/M) Or G0379 (direct referral to observation from physician ofc) On the same day or day before the observation


National APC Rate (2014) = $1,198.91

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G0379 – Direct ReferalG0379 – Direct referral to observation, moved to

APC 608, payment increased to $327.85 (2014) from $175.79 (2013)2012 - reimbursed as a 99211 (APC 604)2013 - reimbursed as a 99205 – new patient clinic

level V2014 – reimbursed between a level IV and V ED E/M

Paid only when observation is not paid Improved reflection of the cost associated

with direct referrals to observation

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Provider-Based ClinicsCMS acknowledges that there is an increasing trend

toward hospital acquisition of physician practicesResulting in increasing numbers of provider-based

clinicsMedicare payments in these clinics are subject to

two co-pays, one for the technical component and one for the professional component

Generally the combination of the two results in a higher co-pay than would be present for a free standing physician’s office

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Provider-Based ClinicsCMS is considering collecting information on these

types of visitsThere several proposed methods for collecting this

information:(1) Creating a new POS (place of service) for off

campus departments of a provider(2) Creating a new modifier that could be reported with

every code provided in an off campus provider based department

(3) Asking hospital to break out costs/charges for these cost centers on the cost report

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Provider-Based ClinicsCMS has received and reviewed the

comments and will let us know what they decide

Watch for more information in the coming year

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Incident-To Guidelines Medicare now requires the compliance with

state law as a condition of payment for services furnished incident to physician and other practitioner services

Would enable the federal government to recover funds paid if services are not furnished in accordance with state law

Should not change anything as providers should have already been following the applicable state laws and state practice acts

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Contact UsRichard Cooley

Phone: 518-430-1144

Email: [email protected]

Matthew LawneyPhone: 845-642-6462


Jean RussellPhone: 518-369-4986


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http://www.EpochHealth.com/

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DisclaimerInformation and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.

January 2014 Jean C. Russell, MS, RHIT [email protected]@epochhealth.com Richard...

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