Teaching physician rules for psychiatry

Psychiatrists use two distinct sets of codes, and so must know two sets of teaching physician rules: the rules for Evaluation and Management (E/M) services (admissions, rounds, established patient office/outpatient visit) and the rules for Psychiatry codes, such as psychiatric diagnostic evaluation and psychotherapy.  The previous blog on this site describes the teaching physician rules for E/M services.  This post will describe the teaching physician rules for using the Psychiatry codes.

 

The Medicare Claims Processing Manual states that the general rules described in the previous section applies to psychiatry.  That is, in order to bill for a service the attending must be present for or personally perform at a separate visit the key components of the service.  The attending must see the patient, participate in the treatment plan and personally document his/her participation in the care.  Supervision and case conference alone is insufficient for an attending physician to report Psychiatry services performed by a Psychiatric resident. 

 

However, for some psychiatry codes, concurrent observation may be substituted.  The rules say, “The general teaching physician policy set forth in §100.1 applies to psychiatric services. For certain psychiatric services, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service by use of a one-way mirror or video equipment. Audio-only equipment does not satisfy to the physical presence requirement.”

Only a physician, not a psychologist, may supervise and report the services of a resident under the teaching physician rules.

For codes selected on the basis of time, such as psychotherapy, only the teaching physician’s time may be counted toward reporting the code.  Do not add together the resident’s time and attending’s time.

Teaching physician rules for E/M services

More than one large institution has run afoul of the rules related to reporting services provided jointly by a resident and an attending, and returned significant funds to Medicare and paid substantial fines.  And yet, the rules are not that complicated and have not changed recently.   This is the key point:  the attending or teaching physician can bill for Evaluation and Management (E/M) services provided jointly with a resident in an approved Graduate Medical Education setting under his/her own provider number only if the teaching physician sees and examines the patient, participates in the treatment and writes a note documenting this service and tying it to the resident’s note.  Three things:  sees and examines the patient, participates in the treatment and writes a note.  If the attending is physically present while the resident is performing the history and exam, that meets the criteria for seen and examined.

 

Let’s look at this one by one.  For an E/M service (admission, office visit, subsequent hospital visit) the attending must perform or be present during the key and critical components of the service.  That is, see and examine the patient.  The attending must participate in the care of the patient and personally document participation.  The Medicare Claims Processing Manual states, “Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.” That is, if the attending does not personally write a note, the service may not be billed.  The attending might see the patient before or after the resident, or in unusual circumstances, at the same time as the resident.  In all cases, the attending must participate in the decision making and treatment plans of the patient.  The attending must personally document the note.  Countersignature, or the simple statement, “Seen and agree” are both insufficient.

Supervision, case conferences, discussions alone: these do not allow the attending to report (that is bill for) a service that a resident provides. 

The Medicare Claims Processing Manual gives examples of acceptable documentation, which I have reproduced below.  Frankly, I suggest adding clinical detail to that patient’s care that day, to avoid the appearance of identical attestation statements. 

Examples from the Medicare Claims Processing Manual

Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.” 


Follow-up Visit: “Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.” 


Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”

Initial or Follow-up Visit: “I was present with the resident during the history and exam.
I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.”

Initial Visit: “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

There is a primary care exception available for some primary care residency programs.  There are different rules for psychiatry, for time based codes and for minor surgical procedures, endoscopies and major surgery.  But they all follow the basic mandate that the attending, under whose provider number the claim is reported and paid, provide part of the service and document the participation.  Supervision alone is insufficient.

 

 

Temporary Billing Guidelines for RHCs

CMS has released temporary instructions for Rural Health Centers in reporting Annual Wellness Visits and the Welcome to Medicare Visit.  I’ve reproduced them below:

Temporary Billing Guidelines for Annual Wellness Visits and Initial Preventive Physical Examinations for Rural Health Clinics

CMS identified an issue with the January 2013 quarterly release that is impacting the payment to Rural Health Clinics (RHCs) for Annual Wellness Visits (AWV) and Initial Preventive Physical Examinations (IPPE) services.

Although, AWV and IPPE are covered services for RHCs, the Fiscal Intermediary Shared System (FISS) is currently preventing the processing of these services at the all-inclusive payment rate.

Until system changes can be implemented in FISS, RHCs should follow the billing instructions outlined below to ensure there is no further delay in your Medicare payments:

  • AWV services should be submitted to the Medicare claims administration contractor with revenue code 052X and HCPCS code G0438 or G0439. Please ensure no other services are reported on the claim with the same line item date of service as the AWV.
  • IPPE services should be submitted by itself on a separate claim to the Medicare contractor.   When billing for an encounter/visit on the same day as an IPPE service, submit the first claim with revenue code 052X and no HCPCS/CPT code. The second claim should be submitted with revenue code 052X and HCPCS code G0402.

Your Medicare contractor may have been holding these claims waiting for a system fix. Therefore, in order to prevent further delay in payments, your contractor will soon begin to return these claims to you. Please resubmit the claims using the billing guidelines as described above.

RHC providers should follow these billing guidelines until further instructions are given. Please contact your Medicare contractor if you have additional questions.

Medicare recouping payments for Annual Wellness Visits

In provider based clinics, the group reports both a facility and a professional fee to Medicare for its services.  CMS is recouping payments when its contractors have paid for both a facility and a professional fee for AWV.

CMS recently released a transmittal and MedLearn Matters article about recouping money when Medicare Contractors had paid for both a facility and professional fee for Annual Wellness Visits.  The AWV is not a covered service under the Outpatient Prospective Payment System, but many provider based clinics reported these services in the same manner as office visits and the Welcome to Medicare Visit.

CMS, however, states that wellness visits are different from the Welcome to Medicare Visit and other office services and these do not have both a professional and technical component.   For billing purposes, either the facility or the physician may report the AWV but not both.  Specifically, this refers to codes G0438 and G0439.  It does not change the reporting of the Welcome to Medicare Visit G0402, which may still be reported with both a facility and professional fee.

The transmittal is 1190, CR 8153 released Feb. 15, 2013.

The MLN Matters article is MM8153.

Your HPI: is should be longer than a tweet

The history of the present illness should be longer than a tweet and twice as informative. 

Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing.

Why bring this up in the context of electronic health records?  Because too often, the HPI in EMR notes is shorter than a tweet.  And less informative.  The history of the present illness describes the reason for the visit and the patient complaints related to the reason.  How about this run on sentence?

The patient presents with a red rash on her forearms that has steadily worsened for three days despite application of calamine lotion and she wonders if while she was gardening she got into poison ivy because she noticed it upon awakening after pulling weeds and it is very itchy.

That sentence is precisely 280 characters, or about twice as long as a tweet.  And here it is with the elements added into the sentence.

The patient presents with a red (quality) rash on her forearms (location) that has steadily worsened (severity) for three days (duration) despite application of calamine lotion  (modifying factor) and she wonders if while she was gardening (context) she got into poison ivy because she noticed it upon awakening (timing) after pulling weeds and it is very itchy (associated sign and symptom).

Our fourth grade English teachers would have encouraged us to break that sentence up into smaller bits, but it does give a clear, concise description of the reason for the visit.  When physicians dictate their notes, the reason for the visit and the symptoms and complaints are usually well documented.  But, when a clinicians switches to an EMR program, documenting the HPI becomes problematic.  Sometimes, the clinician types the HPI into the record.   Who does this make sense to, can I see a show of hands? Take the person with the highest education in the building and ask her to do some typing for you.  Or, a provider can use voice recognition software and “dictate” their HPI and clinical comments in the assessment.  Sometimes, this is time saving.  Sometimes, this results in documentation with clearly recognizable voice recognition errors.  Or, the physician might click, click, click on a template and the output will be single words in the each HPI category or a sentence that may or may not make sense.

It is even more difficult to document the status of a patient’s chronic illnesses in an EMR.  Either the clinician has to type or dictate, or use a template that results in notes that look exactly the same for all patients.  “The patient has received a handout that describes a diabetic diet.”

The problem is, the HPI is one of the most important parts of a medical note for that physician who sees the patient at a later date or for a covering physician.   Failing to document it in sufficient detail, copying it word for word from a previous visit or using single words instead of complete sentences: none of those are helpful.  And, HPIs that are shorter than tweets and half as informative are useless.

 

 

 

 

Transitional Care Management (TCM) update

Date of service: use 29th day following discharge or counting day of discharge as day one, day 30.

Place of service: use place where mandated, bundled face-to-face E/M occurred.

What does licensed clinical staff mean?  No clarification yet from CMS.  FAQ being developed by them.  All staff must practice within their state scope of practice.

If patient is re-admitted during 30 day period, may still bill TCM 30 days after first discharge date if TCM services provided during the period.   May not report to TCM services, one for each discharge/TCM period.

Three New Year’s Resolutions—Coding resolutions that is

Forget the gym, dropping white bread from your diet and forgoing that second glass of wine.  Instead, resolve to improve your coding knowledge and the accuracy of claims you submit in your practice.  Achieving these resolutions will bring certain rewards.

Update your charge documents:  Whether a paper encounter form or charge system within the EMR, review and update.  This advice is as well worn and ignored as “eating more fruits and vegetables.”  But this year, plan two-to-four hours (more for multi-specialty, primary care and general surgery) to review all of the codes and descriptions.  Often, the code is active and valid but the description is misleading or wrong.  Beware abbreviations!  Avoid abridged descriptions!  Your charge document within an EMR or on paper should show full code descriptions and the code.  Don’t use “cryo” which could be codes 17340, 17000, 17110 to name a few of the valid procedures performed using cyrotherapy.

Follow coding and practice management experts on Twitter:  This may sound like an odd place for definitive coding and practice management information, but the brief tweets often link to informative articles.  You can follow me @BetsyNicoletti, of course.  I follow Susan Keane  Baker @Susankb, Kathy McCoy @kathymccoy, the AMA news @amednews, CMS @CMSGov and MGMA @MGMA to name a few.  Or, sign up for a few well selected coding emails, including the one from your own specialty society.  Then, schedule a time to read them.  Save the links to a folder/bookmark all week long, and read them during a regularly scheduled time.  Protect that time.

Get out your CPT book and read the editorial comments:  Really, it’s more fun than the gym.  Why? Answers to many questions are hidden in plain site in the editorial comments of the CPT book.  Can I bill for an ED visit and an admission? (Read the section prior to initial hospital services.)  If I biopsy two lesions on the arm, do I report two lesions or add the lengths of the two together? (Read the section prior to lesion excision.)  If I remove a central venous access device and replace it, do I code for both? (Read the comments before central venous access procedures and review the excellent chart.)

Better coding is within your reach, whether you are a coder, biller or clinician if you set and achieve these three resolutions.