Pecked by a parrot. Oh no, not again!


We’ve all had a lot of fun with the ICD-10-CM external cause codes. But, do we need to use them? The answer to that is no according to the official guidelines and yes if your payers require them. Here is what the official ICD-10-CM guidelines say, “There is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a provider is subject to a state-based external cause reporting mandate or these codes are required by a particular payer, reporting ICD-10-CM codes in Chapter 20, External Causes of Morbidity is not required.” In practice, if your payers currently require you to report E codes on accident and injury claims, they will require these external cause ICD-10-CM codes.

Exactly like in ICD-9, put the injury first: laceration, contusion, fracture. The patient’s injury goes in the first position of the claim form. The second code is the external cause code. Let’s say that cute parrot (or is it a parakeet?) struck my right forearm and caused a contusion. The contusion is reported first, and the cause second. When the physician sees me for the first time, she reports:
S50.11xA Contusion of the right forearm, initial encounter.
W61.02xA Struck by a parrot, initial encounter
The x is a placeholder code because there is no sixth character, and the A is the seventh character extender that tells the payer it was the physician’s first encounter with me for this issue. Both the injury and the external cause require a seventh character.

But, ICD-10-CM also has three additional OPTIONAL occurrence codes. The first reports where the injury occurred. In my case, let’s call it at a zoological garden. How did it happened? That’s the second occurrence code. Finally, was I doing the activity for work, as a member of the military or voluntarily. These three occurrence codes are only reported on the first claim (if you want to report them) and do not require seventh character extenders.

Y92.834 Zoological garden as the place of occurrence of the external cause
Y93.82 Activity, spectator at an event
Y99.2 Activity, volunteer

If I return for treatment to the same physician, the subsequent encounter is reported with the same ICD-10-CM code, S50.11xS. The subsequent encounter doesn’t indicate I’ve been pecked by a parrot a second time (I learned my lesson the first time) but that I’m being seen in follow up care.

My daughter took this picture of me while we were on vacation, and I’m happy to report the parrot didn’t really bite, strike or peck.

Prescription drug management and medical decision making (MDM)

The Documentation Guidelines identify three key components in E/M services: history, exam and medical decision making. MDM itself is divided into three components: the number of diagnoses or management options, the amount and/or complexity of data to be reviewed and the risk of significant complications, morbidity and/or mortality. Not stopping there, this table of risk is divided into three sections: the presenting problem, diagnostic procedure(s) ordered and management options selected. Prescription drug management appears in the management options column of the table of risk and is indicated as “moderate.”

Simple, isn’t it? If prescription drug management is selected as the management option, the table of risk indicates moderate. (Of course, to select MDM, you need two of three of the number of diagnoses/treatment options considered, amount of complexity and selection from the table of risk.)

But, considering prescription drug management, the table of risk does not have any qualifications. It doesn’t say, “new prescriptions, not renewals.” It doesn’t say, “Class 1 drugs only.” It doesn’t say, “but, if it’s an easy problem with prescription drug management, don’t count prescription drug management.” It says, simply, “prescription drug management.”

Some coders incorrectly insert their own judgment into the determination of whether to count prescription drug management. I don’t know of any official citation to support that. I do know the official citation that doesn’t support that: The Documentation Guidelines themselves.

Remember what Dr. McCoy says, “The bureaucratic mindset is the only constant in the universe.” While we are using these complex guidelines, let’s not add to bureaucratic mindset by developing our own guidelines. Use the ones CMS and the AMA developed.

CMS proposes payment for chronic care management in 2015

In the 2015 Proposed Physician Fee Schedule released on the eve of July 4 (CMS loves holiday releases of rules) CMS states they want to support primary care. One of the ways they are proposing to do this is to add a new benefit: chronic care management (CCM). They are proposing a rate of $41.92 for 20 minutes or more of this non-face-to-face service during a 30-day period.

Here’s how they define it Gxxx1: chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days.” (Gxxx1 is a dummy code. CMS will release the HCPCS code in November, when the release the Final Rule.) CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.
In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of condition that poses a real risk to the patient’s health and well being. The practice must implement a care plan that addresses the patient’s conditions and spend 20 minutes during a 30-day period coordinating care and communicating with the patient. The practice must use a certified EHR. In 2015, the version must be certified to at least the 2014 Edition certified criteria. Everyone who has contact with the patient must have access to the electronic record. The EHR must have an electronic care plan accessible to all. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.
The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services. The care plan must be available electronically to all caregivers and available in an electronic or paper copy to the patient.
The practice must inform the patient that they will provide this service and get written consent from the patient to do so. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.
CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office
It looks like a lot of work to me for $41.92. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

Are changes coming to the global period?

CMS released its 2015 Proposed Physician Fee Schedule Rule at 5 pm July 3, 2014. Right before a three day weekend. But, since I’m giving a webinar on the rule July 10, I read away, in between soccer and fireworks. Over the next few weeks, I’ll post summaries of some of the proposals in the rule. On Halloween (CMS loves holidays), when the 2015 Final Rule is released, I’ll add additional posts.

CMS is proposing changes to the definition of the global period, effective in 2017 and 2018. Now, these are proposals and CMS is requesting comments from stakeholders. Nothing in the Proposed Rule is decided on! CMS notes that the payment for 3000 surgical CPT codes includes pre-operative services, intraoperative services and post-operative care. The Office of Inspector General did two reviews, one of Ophthalmology surgical care and one of Orthopedic care. They reviewed the medical records and determined how much post-op care was provided for a sample of these codes. They found that the “value” of the post-op care was less than the value assumed in the surgical care code. Sometimes, the patient receives follow up care elsewhere, and in that case, that physician reports an E/M code. Sometimes, the patient elects not to follow up. The value of the surgical code is built assuming a certain number of follow up visits, and these are not always needed or performed. The value of the codes is assumed to be provided in the office, in a non-facility status. But, some of the services are provided in provider based clinics which have facility status and have lower value. All in all, CMS believes that these global surgical codes may be mis-valued. They are soliciting comments on their proposal to remove post-op care from surgical codes with 10 global days in 2017 and for surgical codes with 90 global days in 2018. It is a proposal and they are asking for our thoughts, opinions and reactions.

It might not be a bad idea. The complaint I hear from most surgeons is about the outliers in the other direction. The post-op patient with multiple co-morbidities who has a non-healing wound and needs more frequent and intense follow up. If there is a mechanism for being paid for those cases, it would be a relief to many surgeons.

Skype ≠ Telemedicine

I got a call from a vendor trying to develop a video conferencing product for a physician to use to talk to a patient who is at home. He said “I’m having trouble finding codes for telemedicine that the doctor can use.” Aren’t we all.

Talking to your patient using a secure video connection doesn’t meet the criteria for telehealth as developed by CMS. There are no current CPT codes that describe that situation. There is no way to report it to the insurance company and be reimbursed for the service. There are CPT codes for non-face-to-face services such as phone calls and on-line medical evaluations, but they don’t describe a video discussion with a patient and have a status indicator of non-covered. (Insurance won’t pay, bill the patient). Interprofessional telephone/internet consultation codes describe physician-to-physician consults and have a status indicator of bundled. (No one will pay.)

What about CMS’s telehealth benefit? Telehealth is a covered service between a patient in an originating setting that is in a Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area. The originating site is a physician office, hospital, critical access hospital, rural health clinic, federally qualified health center, skilled nursing facility or community mental health center. Home is not one of the locations. The patient is located in one of these settings and their provider requests that a distant health professional assess and treat the patient through video-conferencing. There are specific CPT codes that may be reported in these instances. Telehealth as currently defined does not mean that a physician or healthcare professional uses a video-conference to treat their own patient.

Now, you’ll tell me we are moving from fee-for-service medicine into caring for our patients in a way that doesn’t require them to drive to our offices. We have mobile apps for monitoring their well being, and our goal is to keep them healthy and not consuming healthcare resources. (That’s a euphemism for driving up costs we’re at risk for.) But, most of us aren’t there yet. Most of our revenue comes from fee-for-service and there is no CPT or HCPCS code that currently describes a physician using video-conferencing to talk with their patient.

You can download CMS’s telehealth fact sheet



Clues that your SCRIBE is in DISGUISE

Scribes in medical practices are in the news as a way for physicians to more effectively care for patients and use their EHRs. The scribe enters the exam room with the physician and does all of the data entry or typing while the physician takes the history, does and describes out loud the exam and develops the treatment plan with the patient. The scribe doesn’t interact directly with the patient at all, and probably isn’t the medical assistant who roomed the patient. The scribe writes, “Scribed by Betsy Nicoletti.” The physician reviews the scribed note, edits it and signs it.

 But, sometimes, medical practices don’t understand the concept of a scribe. Here are tell tale clues that the person who is “scribing” isn’t really a scribe.

  • Instead of saying, “Scribed by Betsy Nicoletti” the note says, “Dictated for Dr. Palmisano.” Huge warning sign!
  • Your scribe is disguised as a student: Medical student services are never billable services, and a medical practice can’t use the student documentation as a basis for submitting a claim to an insurance company. It usually isn’t the model for students. The student doesn’t sit and type while the clinician asks questions and examines the patient, as a scribe does. In case you need more information on this, page down to my most recent post. This relates to PA and NP students, as well.
  • Your scribe is disguised as an NP or PA or physician with an advanced degree: But, the practice has neglected to enroll the PA or NP with insurances because the medical professional is “only filling in for this week” or “really never works on his/her own.” This is an enrollment issue. Medicare and Medicaid enroll physicians, NPs and PAs, so get them enrolled and report the services appropriately. Contracts with commercial insurers vary. In some models, the PA/NP sees the patient first, does the bulk of the documentation and then the physician arrives and does a briefer visit. Report that service under the PA/NP provider number. “Dictating for Dr. Orthopedist” is not scribing as defined above and does not allow you to report the service under Dr. Orthopedist’s NPI.
  • Your scribe is disguised as an NP or PA and is doing a procedure that typically only a physician or NP or PA would do. Re-read the above example. Your PA/NP may perform procedures independently or incident to. If independently, report under the NP/PA provider number. If incident to, be sure the Medicare incident to rules are met.
  • Your scribe is disguised as you, in the room without you, asking questions or doing an exam, disguised as an independent practitioner: Scribes are typically medical assistants trained to work with a clinician as a scribe in the room. They don’t ask questions, do a physical exam or formulate a tentative plan. They don’t interact with the patient. A scribe is like a fly on the wall, recording what happens in the exam room.

If you are using scribes, that is a terrific way to unchain a physician from data entry. But, look at the list above and make sure your scribe is really a scribe. Don’t use the concept of scribing as a way to not enroll eligible professionals.

Have some extra cash you’d like to send to the government?

No it isn’t tax time. But failing to follow Medicare rules when submitting claims could result in a paycheck for Uncle Sam. In fact, you could have to return money that you’ve already collected from the government. I know three practices that have done that this year, and all for the same reason. What was the reason? Billing for student services. What kind of students? Nurse practitioner and physician assistant students. Students are not licensed and enrolled in Medicare or in any other third-party insurance company and you may not bill for their services.

 Some groups think that if the supervising mid-level provider countersigns the note, or indicates that they saw the patient as well and agreed with the student’s assessment and plan, that they can bill a service under the supervisor’s provider number. Nothing could be farther from the truth. Student services are never billable. It doesn’t matter if the student is a medical student, a PA or NP student, or a physical therapy student or the smartest, brightest, most promising student in the world. You cannot bill for their services.

 But groups want to have students involved in the care of their patients. As a service, they like to take a PA student or an NP student to give those students practice experience. If they do this, only the service provided and documented by the licensed mid-level provider may be reported. A student may document what a staff member may document, which is the review of systems and the past medical, family and social history as long as there’s evidence that the billing provider reviewed this. Most practices want the student to have a fuller experience. I agree with this. Allow the student to see the patient and document the service. However, the supervising clinician must see the patient, examine the patient and document the work performed. When submitting a claim for this service, base the claim only on the work done by the licensed professional and the note documented by that professional.

 Student services are never billable. Unless you want unless you want to send money back to Uncle Sam, don’t make this mistake.