Coding and Billing for Internists’ Services

Challenges and Opportunities

June 2010
 Foundation on which Billing and Coding is Based

 AMA maintains CPT book of codes that describe physician services

 CMS supplements the CPT book as needed
 RBRVS, managed by CMS, determines payment for each physician
service

 Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
 Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
 Medicaid, other government, and private payers generally use RBRVS as
basis for payments
 Medicare Payment Uncertainty
 Medicare annual payment updates lag behind medical
inflation
 Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
 Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect
 Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly
 ACP participating in this messy process to represent the
interest of its members
 Focus on What You Control
 General coding and billing guidance
• Do what is medically necessary
• Document what you did according to guidelines
• Use up-to-date CPT and diagnosis codes
• Investigate payment denials
• Conduct periodic self audits
• Engage in continual coding and billing education

 Understanding coding and billing rules is vital to health of

practice
 Coding and Billing Challenges and Opportunities
 Challenge:
“Welcome to Medicare” Exam Benefit
 Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
 Can bill medically necessary E/M on same date as appropriate—use
modifier -25
 ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
 CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
 Challenge:
Billing for Consultations
 Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician

 Consulting physician can initiate treatment, e.g., diagnostic or

therapeutic tests or procedures, during consultation visit
 On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
 CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
 CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
 Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
 Change was unexpected and has far-reaching implications
 ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
 Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care

 Admitting physician bills initial hospital care code with a

“AI” modifier to distinguish service from consultant(s)
 Payment Implications of Consult Change

 To redistribute the money that Medicare paid for the

no-longer-recognized CPT consult codes:
• Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%

 In general, payments for consult services will be

lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change

Consult 2009 Replacement 2010

Code Payment Code Payment
99241 $48.69 99201 $38.96

99242 $90.90 99202 $67.45

99423 $124.80 99203 $97.75

99244 $184.32 99204 $151.49

99245 $226.52 99205 $190.45

Payment Implications of Consult Change

Consult Code 2009 Replacement 2010 Payment

Payment Code
99251 $48.69

99252 $75.75
99253 $114.70 99221 $94.14
99254 $165.56 99222 $127.33
99255 $201.99 99223 $186.84
Payment Implications of Consult Change
 No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
 Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit

 Physicians who do a significant number of consults will

see overall revenue decline; those who do few see revenue
rise
 Confusion when a secondary payer is involved
Payment Implications of Consult Change

 Can bill prolonged service code in addition to an office or

hospital visit code (as appropriate and if documented)
 Consult can be billed as critical care service if it meets the
CPT definition of critical care
 Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
 Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
 Tips for Billing Private Payers Consults

 Consultants can receive higher payments from private payers still

recognizing CPT consult codes
 Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
 The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
 Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
 Challenge:
Medicare Teaching Physician Regulations
 Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption

 For first two scenarios, teaching physician must

personally see the patient, perform the critical/key
portion of the service, and participate in the management
 Teaching Physician Regulations

 Teaching physician must tether/link note to resident’s note

 Billing is based on the combination of the teaching
physician’s and resident’s documentation
 Examples of acceptable documentation:
• I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
• See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.

 Examples demonstrate saw patient, performed key portion,

and participated in management
Teaching Physician Regulations
 Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone

 Other documentation tips:

• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation

I saw and evaluated the patient and reviewed

(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Attending’s Signature Date

 Teaching Physician Primary Care Exception
 Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
 Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
 Resident must have completed at least six months of
training program
 Teaching physician cannot supervise more than four
residents and must be immediately available to assist
 Challenge:
Billing for “Incident-to” Services
 Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
 Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA

 More complicated incident-to rules pertain to billing of 99212-

99215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
 Billing for “Incident-to” Services
 Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
 Medicare pays 100% of its normal physician fee schedule amount
 PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
 Challenge:
Billing Anticoagulation Management Services
 Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving long-
term, outpatient anticoagulant drug, i.e., warfarin therapy
 ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
 Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
 CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
 The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
 ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
 Check with private insurers to see if they pay for CPT 99363
and 99364
 Opportunity:
E/M Counseling Exception
 Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
 Compare total physician time for encounter to CPT “typical
time”
 Not subject to 1995 or 1997 E/M documentation guidelines
 Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
 List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
 Opportunity:
Home Health Care Plan Certification/Re-certification
 Bill HCPC G0180 for certification of the initial home health care
plan
• Medicare pays $58

 Bill HCPCS G0179 for re-certification of care plan

• Use if patient has received home health services within past 60 days
• Medicare pays $44

 Document thought-process in agreeing with plan and/or in

changing to better meet patient’s needs
 Keep copy of approved care plan in record or be able to access it if
needed
 CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
 Opportunity:
Smoking Cessation Counseling
 Medicare covers for:
• Patients with disease caused or exacerbated by tobacco use; or
• Patients taking medications complicated by tobacco use

 Covers 2 attempts to quit per year

 Each attempt can involve up to 4 counseling sessions
 Bill CPT 99406 for 3-10 minutes of counseling
• Pays $13

 Bill CPT 99407 for >10 minutes of counseling

• Pays $25
 Append modifier -25 to office visit (or other service) done on same date
 Opportunity:
Screening Pelvic/Breast Exam

 G0101 - cervical or vaginal cancer screening; pelvic and

clinical breast examination
 Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
 Pays $35
 Can bill in addition to other same-visit/date services:
• Obtaining a smear for screening Pap test Q0091—pays $40
• Acute/chronic “medically necessary” service, e.g., 99213
• Medicare non covered comprehensive preventive billed to patient, e.g., 99397
 Opportunity:
Use CPT Modifiers as Appropriate
 Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
 Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
 Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
 Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
 Opportunity:
When a Patient is “New” Again
 You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient

 Pay attention when providing office visits, new patient

visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
 Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
 Telephone services
• 99441 - 5-10 min. medical discussion
• 99442 – 11-20 min. medical discussion
• 99443 – 21 -30 min. medical discussion
• Must be initiated by established patient call to physician
• Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days

 E-service
• 99444 – on-line service to established patient
• Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
 Non-covered Medicare Services that Can be Billed
to Patients
 E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
 Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
 Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
 Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
 Opportunity:
Medicare Bonus Payment – PQRI
 Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
 Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
 Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
 ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
 Opportunity:
Medicare Bonus Payment – E-Rx
 Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
 List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
 Receive bonus if correctly report code a minimum of 25 times
in 2010
 Other reporting options, e.g., through an EHR, are available
 ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments
 Regulatory and Insurer Affairs Department
• Brett Baker - bbaker@acponline.org
• Debra Lansey - dlansey@acponline.org
• Tenita Richards - trichards@acponline.org
 Center for Practice Improvement and Innovation
• Margo Williams - mwilliams@acponline.org