2015 coding changes and beyond
By Bradley Reiner
In case you have been wondering if coding and billing will get easier this year, I hate to break the bad news to you that it is only getting more complex. In 2015, some interesting changes in coding have taken place that will be challenging for family physicians to learn and implement. A summary of these new guidelines is outlined below.
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Just when you thought there were enough modifiers, CMS has developed four additional modifiers that will ultimately replace modifier 59. These new modifiers became eligible for use beginning Jan. 1, 2015. They are described below:
- XE – Separate Encounter-Distinct because it occurred during a separate encounter
- XS – Separate Structure-Distinct because it was performed on a separate organ/structure
- XP – Separate Practitioner-Distinct because it was performed by a different practitioner
- XU – Unusual Non-Overlapping Service-Distinct because it does not overlap main service
Why was there a need to add more modifiers to an existing modifier? According to CMS, the 59 modifier is the most widely used modifier. Some providers incorrectly consider it to be the “modifier to use to bypass NCCI.” There has been considerable abuse and high levels of audit activity which has lead to reviews, appeals, and even civil fraud and abuse cases. CMS believes that more precise coding options with better education will reduce the errors. CMS will continue to recognize the 59 modifier but it should not be used when a more descriptive modifier is available. With certain code pairs, only one of the new modifiers will be appropriate and the 59 will not be allowed to bypass the edit. CMS is encouraging everyone to begin using the correct modifiers to avoid denials in the future.
CMS has not yet released any examples to help illustrate how to use the new modifiers correctly. In my research I was able to find some possible scenarios on how these four might be used. For example:
- XE – Separate surgical operative session on the same date of service (8 a.m. and 4 p.m.)
- XS – Injection into tendon sheath, right ankle and injection into tendon sheath, left ankle
- XP – Patient seen in the office by FP who encounters a problem and has to call in a specialist to provide a service on the claim
- XU – Diagnostic cardiac angiography leads to therapeutic angioplasty
Although these are not official examples from CMS, these samples should give you a better idea of how to use the modifiers more accurately. It is important to begin using them now in your daily billing and coding. Even though modifier 59 will still be recognized by CMS, they expect to terminate its use and require one of the four new modifiers in the future. Don’t delay. Begin using them now to avoid problems later.
Chronic Care Management
CMS is recognizing the importance of chronic care management among primary care physicians and the need to be paid for monthly management of these conditions. Because of this CMS is now reimbursing physicians for the management of chronic care conditions. A new CPT code was developed with the following definition:
Chronic care management services, at least 20 minutes (non-face-to-face) of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months or until death
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- Comprehensive care plan must be established, implemented, revised, or monitored
- Gives providers and clinical staff an opportunity to be paid for non-face to face services
The national average reimbursement is $40.39 and is payable by Medicare Advantage plans as well. All practitioners will be allowed to bill this code, including extenders, while no more than one provider can bill for CCM. No prior services are required to bill CCM, but the provider must obtain a beneficiary’s consent.
The services covered in CCM include:
- Access to care management for chronic treatment
- Continuity of care
- Care management for chronic conditions
- Creation of a care plan
- Management of care transitions
- Coordination of home or other facilities
- Communication with caregivers
- Electronic capture and sharing of information
The big point to be made above involves the creation of a care plan. A care plan is essentially a questionnaire about the problems experienced by the patient and the goals they have for treatment. These include:
- Top concerns or Barriers
- Symptom management
- Other health care providers
- Resources and support
- Treatment goals and targets
- A summary of things the patient needs to do
As stated earlier, a beneficiary must give consent to have non-face-to-face chronic care management services provided. CMS has not created a form, but has given information on what is required by the beneficiary for approval.
Time spent providing services on different days or by different clinical staff in the same month may be aggregated to a total of 20 minutes. If two staff members are providing services at the same time, only the time spent by one individual may be counted. Less than 20 minutes cannot be rounded up. In addition, only general supervision is required. It is not required for a provider to be on site. Telephone availability is all that is needed.
Finally, Family Practice Management in its January/February magazine published a very thorough article on CCM. In it, they developed a sample care plan document for physicians to use as well as a sample beneficiary acknowledgment letter. The article also has a CCM services log so staff managing conditions through the month can log their time to meet the 20 minute threshold. All of these forms can be found in this article located here.
Advanced Care Planning
Payers are recognizing the importance of advanced care planning and end of life directives. These require a substantial amount of time and effort to complete. Two new codes were developed this year to address these issues in more detail. The codes are CPT 99497 and 99498.
Face-to-face encounter not requiring the patient. The codes are time based with the first 30 minutes required to bill 99497 and each additional 30 minutes bill 99498. No active medical management is required and it includes the explanation and discussion of advanced directives. Although this is still not paid by Medicare, a recent article discussing these codes suggests that it is a matter of time before Medicare reimburses them. Although Medicare doesn’t pay them yet, it is possible that other payers will recognize them. Begin researching with your payers now to determine if these are payable codes or when they will be added.
Value Based Modifier
Payment methodologies surrounding quality of care are becoming a standard for CMS as well as other payers. It is only a matter of time before providers will be paid based on quality of care and outcomes. CMS’s Physician Quality Reporting System is one standard that is being required and payment will be reduced if physicians are not participating. A payment differential will be implemented among all eligible providers receiving reimbursement under the Medicare Physician Fee Schedule. The breakout is as follows:
- In 2015, physicians in groups of 100 or more are required to participate. If they do not participate, a 1 percent reduction will be implemented.
- In 2016, physicians in groups of 10 or more are required to participate. A 2 percent reduction will be applied for non-participators.
- In 2017, all eligible providers will be required to participate.
How do you begin the process? Start by reviewing this link from CMS. This will give you direction on how to begin participating in PQRS.
OIG Work Plan
The congressional watchdog ensures payments made by the federal government are appropriate as well as enforces a variety of measures to ensure that systems and polices are enforced. The U.S. Department of Health and Human Services Office of Inspector General Work Plan for fiscal year 2015 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. For FY 2014, OIG reported expected recoveries of over $4.9 billion, consisting of nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables. This includes about $1.1 billion in non-HHS investigative receivables resulting from their work in areas such as the States’ shares of Medicaid restitution. They reported in FY 2014 exclusions of 4,017 individuals and entities from participation in Federal health care programs; 971 criminal actions against individuals or entities that engaged in crimes; and 533 civil actions, which include false claims and unjust-enrichment lawsuits. Needless to say, this is big business and a significant amount of revenue can be generated from these investigations.
There are few areas that are being reviewed carefully in 2015 and beyond.
Outpatient services billed as new patients when the physician or a physician of the same group of the same specialty saw the patient within the last three years. Overpayments have occurred when billing new patient visits when the patient is established.
TIP—Ensure all outpatient and office visit services are billed based on the three year rule.
Coding errors have occurred when the place of service has not been appended correctly. Payment is higher when services are provided in the office than hospital based facilities. Massive overpayments have been occurring because of inaccurate coding of the place of service.
TIP—Ensure all place of service coding is based on where the service was provided.
Evaluation and Management Services continue to be reviewed although it is not specifically on the list for 2015. OIG is specifically reviewing code levels and the documentation required. There is an increased focus on records that have the same identical information across patients (cloning of records).
Tip—Ensure documentation meets code levels and document only what’s necessary based on the nature of the presenting problem.
Errors have occurred in using modifiers during the global surgery period. These include:
- Modifier 24-Unrelated E/M during post-op
- Modifier 78-Return trip surgery (related)
- Modifier 79-Return trip surgery (unrelated)
Tip—Review all modifiers and ensure the correct one is appended.
Bradley Reiner, formerly with Texas Medical Association, has been owner of Reiner Consulting and Associates for 15 years. He is TAFP’s endorsed consultant and is a billing and coding auditor for the Texas Medical Board. He can be reached at (512) 858-1570 or firstname.lastname@example.org. See more about the services Reiner provides to TAFP members at www.tafp.org/practice-resources/reiner.