Saturday, December 30, 2017

How Should You Code Pre-Op Exams and Who Can Perform Them?

On the surface, coding preoperative visits is relatively straightforward: Choose the evaluation and management (E/M) code that most accurately represents the medical decision-making and patient acuity.

However, there’s more to it than that, and coders need to understand the nuances of reporting these visits if they want to avoid payer scrutiny, says Raemarie Jimenez, vice president, member and certification development at AAPC, an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists and practice managers. “It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.”

Jimenez provides the following five best practices to help coders report preoperative visits correctly and avoid costly denials.

1. Recognize That Not Every Patient Requires Pre-Op Clearance

The purpose of a preoperative visit is to evaluate a patient’s complicating health condition to determine whether he or she can withstand surgery. Healthy patients don’t generally require a preoperative visit, and providing one may not be medically necessary. Surgeons may evaluate healthy patients to determine whether surgery is necessary; however, they don’t typically need to send these patients to a primary care physician, internist, or specialist to clear them for the surgery. 

2. Know Who Can Perform Pre-Op Clearance

Specialists and internal medicine physicians are among those who most frequently perform preoperative clearance because they’re the ones typically managing the conditions that could affect surgery.

Surgeons may try to bill these visits without realizing that any preoperative evaluations they perform after the decision to perform surgery is made are included in the global surgical package. The global package also includes the visit during which the surgeon performs a preoperative history and physical (H&P). Per CPT guidelines revised in 2016, surgeons can’t bill the H&P separately using modifier -24.

In addition, the global package includes any related subsequent visits that occur prior to the surgery but after the decision for surgery is made. For example, a patient decides to have surgery but then delays surgery for a few months due to scheduling conflicts. The surgeon brings the patient back into the office for an evaluation the day before surgery.

This additional visit is not separately billable, says Jimenez. “The payer says, ‘Ok, we’re paying you for the entire package. Don’t unbundle services we are already paying for,’” she adds. If it’s unrelated to the surgery, it’s separately reportable using a diagnosis that’s also unrelated to the surgery.

3. Report At Least Three Different ICD-10-CM Diagnosis Codes

Visits for preoperative clearance require ICD-10-CM codes that denote the following information:
  • Intent for pre-operative clearance (Z01.81x)
  • Diagnosis for which clearance is requested
  • Diagnosis for which the patient is undergoing surgery

Note that ICD-10-CM code Z01.81x requires additional specificity regarding the purpose of the preoperative exam (i.e., for cardiovascular exam, respiratory exam, laboratory exam, other preprocedural exam, allergy testing, blood typing, or antibody response exam).

Consider this example: A surgeon sends a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) to a pulmonologist for preoperative clearance so he or she can undergo knee surgery to alleviate right knee pain due to osteoarthritis. The pulmonologist should report an E/M code for the office visit as well as the following three diagnosis codes (in this order):
  • Z01.811 (Encounter for preprocedural respiratory examination)
  • J44.1 (COPD with acute exacerbation)
  • M17.11 (Unilateral primary osteoarthritis of the right knee)

The sequence of the codes is important because the Z code indicates to payers that the purpose of the visit is for preoperative clearance, says Jimenez. Note that physicians could report more than one Z code depending on the number of systems they evaluate. When reporting multiple Z codes, they should also remember to report the additional diagnoses for which the examinations and clearance are required.

For example, an internist might examine the patient’s COPD and cardiac arrhythmia for preoperative clearance. In this case, report Z01.811 as well as Z01.810 (encounter for preprocedural cardiovascular exam) as well as the ICD-10-CM diagnosis codes that denote the COPD and arrhythmia. This is in addition to the reason for surgery (reported last in the sequence).

4. Ensure That Documentation Supports Medical Necessity

To justify medical necessity, documentation should include the following details:
  • Any condition(s) the physician evaluates to clear the patient for the anticipated surgery
  • Whether the patient is cleared for surgery and why
  • Reason(s) why the patient isn’t cleared for surgery and any course of action that’s necessary to enable clearance (e.g., prescribe a course of antibiotics to treat congestion)

5. Distinguish Between ‘Clearance’ and ‘Decision for Surgery’

Unlike visits for preoperative clearance, surgeons can bill for visits to discuss the decision for surgery. Report an E/M code with modifier -57 (decision for surgery) when the encounter is the day before or the day of a major surgery. When the encounter occurs prior to the day before surgery, modifier -57 is not required.

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Friday, December 29, 2017

2018 MACRA Update for Small Practices

Earlier this summer, CMS released the proposed rule for the 2018 Quality Payment Program. As we move into the fall and the final months of recording 2017 data, let’s take another look at the rule for next year and see how practices can prepare for the changes that may come in the second year of the program. Below is a set of key points that summarize the proposal.

1. The QPP Is Alive and Growing

There are significant changes in the new proposed rule relative to the 2018 plans laid out in the final rule governing the 2017 performance year, but the majority of the program is the same. Core program elements, such as performance categories and the structure of the program tracks, remains unchanged. Future program requirements look to be ramping as expected, as discussed below.

What does this mean for the small practice? MIPS has a definite and accelerating path, and now is a good time to get comfortable as the program ramps up the requirements over the next few years.

2. MIPS Cost Category in 2018

CMS has proposed that cost will again account for 0% of the composite performance score in 2018 and not impact payments in 2020. While this is still not the final rule, it has momentum, and CMS is requesting feedback before the final rule is published. Based on this information the category weights would stay the same in 2018 as they did in 2017, with Quality counting for 60%, Advancing Care Information counting for 25%, and Improvement Activities counting for 15%.

What does this mean for the small practice? While not directly responsible for cost outcome, it is a good idea to monitor and understand the process and your data now, expect inclusion of Cost in your Composite Performance Score in 2019.

FINAL RULE UPDATE: Notably, CMS will begin to assess providers on cost measures in 2018—a significant change from the proposed rule, which initially delayed the cost measures entirely until 2019. The cost category will be weighted at 10 percent of the MIPS final score in 2018 and will increase to 30 percent in 2019. Collectively, quality and cost performance will likely become a key determinant of high-performing providers.

3. More Flexibility for Small Practices

CMS is proposing to increase the planned thresholds for low volume exclusions in 2018. The 2017 thresholds, where clinicians or groups with ≤$30,000 in Part B allowed charges or ≤100 Part B beneficiaries. CMS is proposing thresholds of ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries to qualify for exclusion in 2018.

What does this mean for the small practice? Low volume Medicare Part B practices may be excluded in 2018, to a larger degree than in 2017. All low volume practices should check their Medicare Part B metrics to determine their status.

FINAL RULE UPDATE: CMS confirmed the minimum thresholds. Providers are excluded from the QPP in 2018 if they bill $90,000 or less in Part B allowed charges or see fewer than or equal to 200 Part B beneficiaries.

4. Bonus Points Proposed

CMS has proposed adding additional bonus points to increase flexibility and reward clinicians and groups who have more difficulty scoring well in MIPS:

Proposed: Up to 10 percentage points available for performance improvement in the Quality category. This bonus will be based on the rate of improvement in the Quality category score between the 2017 performance year and the 2018 performance year.

Proposed: Additional bonus of up to 3 points available for eligible clinicians based on the medical complexity of patients they see. The assessment of medical complexity may be based on the average Hierarchical Conditions Category (HCC) risk score.

Proposed: A bonus of 5 points automatically awarded to any eligible clinician or group in a small practice with 15 or fewer clinicians.

What does this mean for the small practice? Small practices now have an added handicap that allows them to score bonus point to offset their small size, complex patient population and relative improvement in MIPS performance.

FINAL RULE UPDATE: Bonus opportunities added in 2018 performance year -

Clinicians can use a 2014 Edition and/or 2015 Edition Certified EHR. However, you receive a 10% bonus to your ACI score if you only use a 2015 Edition CERHT. 

Receive up to 5 bonus points on your final score for treatment of complex patients.
Small practices receive 5 bonus points to their final score. 

A 5% ACI bonus is available for submitting to an additional public health agency or clinical data registry not reported under the performance score. 

5. Virtual MIPS Groups are Proposed

Virtual Groups will be comprised of eligible clinicians in solo practices or groups of 10 or fewer clinicians who elect to jointly participate in MIPS. By doing so small practices can offset low scores with other practices that may have high scores and improve both practices overall performance. The group as a whole reports the combined score which is attributed to each practice in the virtual group.

What does this mean for the small practice? Identifying your practice's areas of high and low MIPS performance and joining a Virtual Group to offset each other will lead to much better MIPS scores for all the practices in the Virtual Group. You will need to elect to participate in a Virtual group in 2018 prior to the start of the 2018 performance period.

FINAL RULE UPDATE: Solo providers and small practices can form a virtual group without specialty or location limitations to participate in MIPS together. Those interested in the virtual group option should review the Virtual Groups Toolkit. The virtual group electronic submission deadline is December 1, 2017 for the 2018 performance year. Providers considering this new option for 2018 must act quickly.

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Tuesday, December 26, 2017

Sessions rescinds protection against excessive fining by local courts

Over the course of the past week, Attorney General Jeff Sessions [official website] has revoked [DOJ press release] a total of 25 Obama-era Department of Justice (DOJ) guidelines. Among them was a 2016 guideline [text, PDF] that advised local courts to not hand down or enforce unnecessary and excessive fines on those without the means to pay them.

The 2016 guideline was initially put in place by Vanita Gupta [ACLU profile], the former head of the Civil Rights Division [official website] of the DOJ, roughly one year after the DOJ released a report [text, PDF] on its investigation into excessive fine enforcement in Ferguson, Missouri. The report found that:

The municipal court does not act as a neutral arbiter of the law or a check on unlawful police conduct. Instead, the court primarily uses its judicial authority as the means to compel the payment of fines and fees that advance the City's financial interests. This has led to court practices that violate the Fourteenth Amendments due process and equal protection requirements.The report additionally found that Ferguson courts issued a total of 9,000 warrants in 2013 alone for failure to pay excessive fees attached to minor violations such as parking infractions, traffic tickets, and housing code violations.

Since taking over the DOJ, Sessions has disapproved of using guideline protocols to drive policy. In a November memo[text, PDF], Sessions stated that:

the Department has in the past published guidance documents—or similar instruments of future effect by other names, such as letters to regulated entities—that effectively bind private parties without undergoing the rulemaking process. The Department will no longer engage in this practice. Effective immediately, Department components may not issue guidance documents that purport to create rights or obligations binding on persons or entities . . .Following the release of the November memo, the DOJ has been undergoing a "review and repeal" process to rescind any guidelines that run counter to this belief.

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Saturday, December 23, 2017

6 Tips to Achieve a 96% Medical Billing Net Collection Rate

When was the last time you examined your net collection rate as part of a ‘financial health and wellness’ checkup? Monitoring this rate has always been important; however, it is absolutelycritical in the current healthcare environment.

Why? Two main reasons. First, many insurers have become more demanding in terms of documentation specificity and thus more liberal with denials. Second, high deductible health plans have shifted much of the financial burden directly onto patients who aren’t always willing—or able—to pay. When this happens, uncollected amounts can skyrocket, sending a practice into a nosedive of financial turmoil. And now, with the average patient financial responsibility for family coverage having increased 78%, it's time to pay closer attention.

At the end of the day, all practices must ask this question: How do you know whether you’re being paid correctly if you’re not monitoring your collections?

Calculate, monitor your net collections rate
The net collection rate measures a practice’s effectiveness in collecting all legitimate reimbursement—that is, the amount the practice is owed after payer contract adjustments are made. It also reveals how much revenue is lost due to bad debt, untimely filing, payment posting errors, claim underpayments, and a variety of other reasons. Financially healthy practices are those that maintain a net collection rate of 96% or higher over a sustained period of time.

Not sure how to calculate your net collection rate? Consider the following five steps:
Identify a time period that you want to monitor (e.g., 90 days). Use aged data (typically from 4-6 months ago) to ensure that the majority of claims used for the calculation have had ample time to clear.

Calculate total payments (from payers and patients) for the designated time period.
Calculate total charges minus approved write-offs (e.g., due to contractual reasons, bad debt, professional courtesy discounts, etc.) for the designated time period.

Divide your calculation in step 2 by your calculation in step 3. Then multiply by 100.
Do this consistently (e.g., every 90 days) for a period of at least one year to get the most accurate average rate.

6 tips to boost your net collection rate

If you’re not satisfied with your net collection rate, the good news is that you can improve it by focusing on patient engagement as well as tracking insurance payments more closely. Consider the following:

1. Use front-end point-of-service collections. Set a goal to collect 100% of copayments and, if possible, deductibles at the time of service. This requires appointment reminders that they must pay the copayment and/or deductible at the time of their visit. If the patient isn't able to cover the financial responsibility, offer options including rescheduling the appointment or other payment options.

2. Invest in patient education. Consider designing a brochure or quick-reference sheet for patients to help them understand the ins and outs of insurance payments and why they may be financially responsible for the bulk of the services they receive. Also, include contact information for insurers with which the practice participates so patients can contact those companies with specific questions about their own coverage. Ensure that someone within the practice is always available—and well-equipped—to answer financial questions. This may require additional staff training, but it’s well worth it in terms of being able to boost collections.

3. Review your patient statements. Could they use an overhaul so patients understand the information on statements more easily? Would it be more cost-effective and efficient to work with an external vendor to assist with generating and sending patient statements in a timely manner?

4. Provide patients with payment options. Accept payments via cash, checks, debit cards, and credit cards. Also, ensure that patients can pay via the patient portal, the practice’s website, and in the office upon check-in. Some practices also offer a payment plan for patients who indicate they are willing to pay their bill in installments. Be sure to document the parameters of this plan, including the terms of payment and what happens if the patient misses a payment. Obtain the patient’s signature on this document.

5. Consider working with a collections agency. Although there’s a cost associated with hiring an agency, this may be a last resort to collect monies owed. Agencies usually charge a contingency fee of 30% or a flat fee (typically $2-$15 per account). Most practices wait until balances have remained unpaid for at least 75 days before turning the account over to collections.

Note that some agencies specialize in ‘soft’ collections, meaning they contact patients with an ‘early warning’ within 30-60 days after payment is due. This approach may be more successful because patients often view it as less demanding and confrontational. Either way, look for an agency that strives to maintain professional courtesy and respect when contacting patients.

6. Don’t assume that patients are the problem. Calculate your net collection rate by payer to identify whether a particular payer is the culprit. Is the payer paying correctly per the contracted rate? Does the payer continually deny a service for no apparent reason?

If nothing turns up, keep digging. Does the practice struggle with submitting claims per timely filing requirements? Is an EHR glitch causing a billing error? Is a repetitive coding error causing denials? Do front-end staff members update demographic and insurance information at each appointment so claims process smoothly?

There are many reasons why a net collection rate may be subpar. Finding the root cause will help the practice take proactive steps to improve collections and become more financially healthy.

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Wednesday, December 20, 2017

European high court rules Uber must comply with taxi regulations

The European Court of Justice (ECJ) [official website] ruled [judgment] Wednesday that Uber must comply with existing transportation regulations.

In doing so, the ECJ found that Uber operates more like a transportation company than an online platform that merely connects riders with drivers. This ruling will require Uber operating in an EU country to abide by the transportation regulations of an individual member state as opposed to the less restrictive e-commerce rules of the EU.

In a press release [text, PDF] accompanying the decision, the court stated that

the service provided by Uber is more than an intermediation service consisting of connecting, by means of a smartphone application, a non- professional driver using his or her own vehicle with a person who wishes to make an urban journey ... that intermediation service must be regarded as forming an integral part of an overall service whose main component is a transport service and, accordingly, must be classified not as "an information society service" but as "a service in the field of transport" ... [C]onsequently, the directive on electronic commerce does not apply to that service, which is also excluded from the scope of the directive on services in the internal market. For the same reason, the service in question is covered not by the freedom to provide services in general but by the common transport policy. However, non-public urban transport services and services that are inherently linked to those services, such as the intermediation service provided by Uber, has not given rise to the adoption of measures based on that policy.

While this has broad implications for Uber and other ride-hailing apps wishing to expand their influence in the EU, this ruling only pertains to Uber's peer-to-peer ride-hailing service, which has already faced a ban in numerous EU countries such as France, Spain and Belgium. Moreover, Uber already operates under the transportation regulations of numerous EU countries.

Post It Notes















Senate passes (slightly different) sweeping tax bill

The US Senate [official website] on Wednesday voted 51-48 along party lines to approve a slightly modified version of the conference committee version [text] of the Tax Cuts and Jobs Act[H.R. 1 materials].

The bill underwent minor changes between Wednesday afternoon's passage [JURIST report] by the US House of Representatives [official website] after the Senate Parliamentarian struck three provisions [JURIST report] under the Byrd Rule[materials]. That procedural rule governs the content of bills that may be passed through reconciliation, and thus require only a majority of approval in both houses.As a result, the version passed by the Senate is slightly different than that passed in the House earlier today. Because both houses must pass an identical bill before the President can sign it into law, this means that the House will have to vote on the bill again tomorrow, with the offending provisions stricken.

Because the substance of the bill remains largely the same as the version passed by the House, allow us to quote ourselves:

Among the changes the bill would make are the the reduction of the corporate income tax rate from 35% to 21%, and the setting of marginal income tax rates at 10%, 12%, 22%, 24%, 32%, 35% and 37%, with accompanying changes in the income brackets to which those rates apply. Notably, the top marginal tax rate doesn't kick in until $500,000 individuals and $600,000 for those who file jointly, an increase in the thresholds of $418,400 and $470,700, respectively, under current law.

The conference bill also raises the child tax credit from $1,000 per child in 2017 to $2,000 per child and makes up to $1,400 of the credit refundable. For slightly different kinds of families, the current estate tax exemption of $5 million per individual and $10 million per couple were more than doubled to $11 million per individual and $22 million per couple.

Many of the more controversial aspects of the earlier bills did not survive the committee process. Student loan interest will still be deductible, teachers can still benefit from a $250 credit for classroom supplies,children must still be born to benefit from 529 savings accounts and certain medical expenses remain deductible as under the current code.

The bill also makes changes to the carried interest deduction [Tax Policy Center materials], requiring that assets be held for three years as opposed to one year under current law in order to benefit from the preferential 23.8% tax rate.

Apart from these changes to taxation directly, the bill will also effectively repeal the individual mandate provision of the Patient Protection and Affordable Care Act (ACA) [text], which currently imposes a $695 tax penalty on filers who don't have minimum insurance coverage. Although the penalty remains technically in effect, the amount of the penalty is set at $0. This method of repeal closely mirrors the Supreme Court's 2012 decision finding the individual mandate constitutional because it is a tax [JURIST report].

The House is expected to vote on the version passed by the Senate early tomorrow morning.

Post It Notes