Understanding How MACRA and MIPS Make Documentation Matter Even More

Discover why your success in this QPP track depends on documenting.

You probably don’t need to be told Medicare physician reimbursement is currently seeing, as Modern Healthcare put it, “its biggest change since its launch in 1965.” To avoid financial penalty, approximately 622,000 U.S. clinicians (as estimated in CMS’ final rule about the program) must now participate in the Quality Payment Program CMS established to implement MACRA, the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015.

What you might need is help understanding how MACRA, MIPS, APMs, bundled payments and other efforts to “drive the [U.S.] health care system towards greater value-based purchasing” affect your practice. As the U.S. healthcare system’s shift away from fee-for-service reimbursement gathers speed, it’s only natural providers have concerns and questions, MACRA is particularly far-reaching and complex. “Meaningful use is first-grade arithmetic,” Healthcare IT consultant Dan Golder told Modern Healthcare, referring to a familiar EHR incentive program MACRA is sunsetting, “and MIPS and MACRA are college-level calculus… The complexity of MIPS is going to be very difficult for physicians to stomach.”

MDCodePro specializes in helping practitioners increase their coding accuracy, regulatory compliance, and profitability. As we noted in our discussion of new U.S. tax law, we don’t presume to present expert legal or financial advice. But while we can’t offer a comprehensive review of MACRA’s many provisions (the final ruling runs 1,653 pages, Healthcare Informatics reports,) we can help you refresh your understanding of MACRA’s basics and point out some of its impact on how you document the services you provide your patients, because documentation is always key in optimal coding.

A Summary of MACRA MIPS and APMs

MACRA uses a two-track Quality Payment Program (QPP) to reward practitioners for quality care delivered to Medicare beneficiaries:

• The Merit-Based Incentive Payment System (MIPS) consolidates current pay-for-performance programs and determines payment bonuses, penalties, and adjustments based on providers’ scores in four categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHRs. Providers have the flexibility of choosing the MACRA MIPS quality measures most appropriate to their practices.
• Advanced Alternative Payment Models (APMs) incentivize high-quality, cost-effective care by exempting qualifying participants from MIPS reporting requirements and payment adjustments.

The existence of “MIPS APMs” complicates the QPP’s two-track structure somewhat; however, according to CMS, “[m]ost Advanced APMs are also MIPS APMs.” Most clinicians will participate in the MIPS track. Clinicians or groups serving 200 or fewer Medicare Part B beneficiaries or who have billed $90,000 or less to Medicare are exempt.  

Checking your participation status is vital. (You can do so here.) Penalties for eligible practitioners who aren’t participating will reach as much as 9% by 2022, while participant rewards will climb equally as high.

Why MIPS Demands You Increase Attention to Documentation

MACRA will impact medical coding in a very practical way because, in some cases, it necessitates new codes. For example, because the law aims to improve coordination of care among providers across specialties and settings, it requires CMS develop new codes for identifying episodes of care and patient condition groups, plus group classification codes.

But any understanding of MACRA and MIPS that doesn’t consider the law’s implications for documentation, so foundational to sound coding, would be incomplete. “It’s important to remember,” write Kathryn DeVault and colleagues for AHIMA, “that accurate documentation and complete and compliant coding impacts almost all areas of quality reporting and, ultimately, provider reimbursement.”

Writing for the AAPC, billing and coding expert and instructor Rhonda Buckholtz makes MIPS’ stakes clear: “MIPS starts in 2019 with 4 percent on the line…That could add up to over $200,000 for even smallish practices. Who couldn’t use that much extra revenue in their practice? Which one of us can afford to lose that much?”

Dedicate Yourself to Improved Documentation with MDCodePro

As part of your adjustment to MACRA, then, decide to make your medical coding as strong as possible with MDCodePro.

Our methodology, which has been validated in repeated audits, equips you to document each patient visit to support its optimal CPT® code. Our short series of video lectures streamline CMS’ complicated coding regulations into a manageable and memorable system you can put into practice right away. And our easy-to-use code generator uses the data you give it to identify the code ensuring your greatest accuracy, regulatory compliance, and legitimate reimbursement.

Don’t let weak documentation keep you from full compliance with MACRA or the revenue to which you’re entitled under the new law. Sign up for MDCodePro today.

The post Understanding How MACRA and MIPS Make Documentation Matter Even More appeared first on MDCodePro.

source https://mdcodepro.com/blog/understanding-macra-mips/

Costly Mistakes to Avoid When Using CMS Billing Modifiers

Master these commonly misused modifiers for improved compliance and revenue.

Despite the thousands of CPT® codes in the codebook (some 10,000 as of 2016,) you still won’t find a code to perfectly fit every possible circumstance. That’s when you need to know how to use CMS billing modifiers to ensure you’re properly reimbursed for your work.

Modifiers communicate important information about a procedure’s specifics, and details directly affecting how much you will be paid. But they frequently lead to coding and billing mistakes. And these mistakes can cost you not only money but also time and energy spent correcting them.

Because we care about increased healthcare provider efficiency and productivity at MDCodePro, we want to point out some modifiers practitioners commonly find problematic. By reviewing our short list of CPT® modifier definitions and examples, you can avoid some of the pitfalls tripping other providers up.

A Brief Guide to Billing with Frequently Misused CMS Modifiers

Modifier 25

Modifier 25 appears to be one of the most commonly misused CMS billing modifiers. Just last year (2017,), CMS flagged potential Modifier 25 misuse as a problem, noting 19% of codes for 0-day global services (services whose valuation already includes routine E/M) were billed with Modifier 25 over half the time. This misuse suggests Modifier 25 may still be causing as many problems as it did in 2005, when a notable OIG report found a full 35% of claims using it failed to meet Medicare requirements, resulting in $538 million of improper reimbursement.

The CPT® manual defines Modifier 25 as “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.”

This definition means not every additional service a provider decides to perform on the same day as another procedure warrants the modifier. A service must be “above and beyond” what is normally required in the other procedure’s pre- or post-operative services, as the Bulletin of the American College of Surgeons (ACS) states. For example, coding consultant Emily Hill points out Modifier 25 sometimes properly distinguishes E/M service from an actual injection or drug administration, but “some immunization codes include counseling the patient.”

“A knowledgeable individual, looking at the available documentation,” writes the AAPC’s John Verhovshek for Physicians Practice, “should be able to identify the important E&M components of history, exam, and medical decision-making (MDM,) apart from any other procedures or services performed on the same day.”

To avoid misusing Modifier 25, make sure your documentation supports the service as significant, medically necessary, and separately identifiable; and that the same provider (including different physicians in the same group practice) performed the service.  Append Modifier 25 only to E/M codes, not procedure codes. And consider using Modifier 25 instead of Modifier 59; as CMS emphasizes, Modifier 59 “should not be appended to an E/M service.”

Modifier 24

Modifier 24 identifies an “[u]nrelated E/M service by the same physician during a post-operative period.”

“Unrelated” is the key. Your documentation must show you performed the medically necessary service solely to treat the underlying condition, and not as a part of routine post-operative care included in the surgical package. Medicare does not allow separate billing for post-op medical and surgical complications unless they require another trip to the OR, as coding expert Betsy Nicoletti writes for Physicians Practice.

Emily Hill writes Modifier 24 is “often overlooked” and suggests practices keep “an easily accessible list of the global periods for office-based procedures [to help them] remember whether a modifier is required.” (You might consider keeping a list of relevant CPT® modifiers and their definitions close by, as well.)

Be certain you don’t confuse Modifier 24 with Modifier 79. The former describes unrelated E/M services; the latter, an unrelated, non-E/M service or procedure.

Modifier 57

Modifier 57, “Decision for Surgery,” is appropriately applied to an E/M service not included in the surgical package, but an initial consultation or evaluation in which the physician determines a major surgical procedure (one with a 90-day global period) is necessary.

Providers sometimes mistakenly apply Modifier 57 when Modifier 25, discussed above, is the proper choice. Modifier 25 is appropriate for minor procedures—John Verhovshek offers “many injections, minor integumentary repairs, and endoscopic procedures” as examples—while Modifier 57 should be reserved for major ones.

Nor should Modifier 57 be used when decisions for elective surgeries are made, as such decisions “typically are made at a previous outpatient encounter,” as billing and coding expert Carol Pohlig writes for The Hospitalist. But Modifier 57 should sometimes be used with Modifier 24, when the E/M service leading to the decision for surgery occurs in post-op period of another, unrelated procedure.

When you use Modifier 57, be certain the documentation in the patient’s record supports your decision for surgery itself, not simply your pre-operative clearance of the patient for surgery.

Modifier 26, TC, PC

Some procedures present complicated coding questions because they contain both a professional component, or “PC” (supervision, interpretation, and reporting) and a technical component, or “TC” (the costs of the equipment, supplies, and technical support necessary for the procedure, as well as practice and malpractice expenses.) For example, diagnostic tests and radiology procedures generally involve both PC and TC.

If a single physician or practice performs both parts of a two-component procedure (for example, a doctor at an independent clinic orders and reviews an X-ray taken on-site,) a single, global CPT® code will suffice. But in many cases, separate payments for PC and TC are in order, as when a physician interprets a test administered at another facility.

Modifier TC claims reimbursement for a service’s technical component only. But, somewhat confusingly, the modifier for professional component only is Modifier 26; Modifier PC indicates the wrong surgery was performed on a patient.

Remember: Some CPT® codes are standalone codes, indicating professional-component and technical-component only services. Don’t use Modifier 26 with the former group or Modifier TC with the latter.

Develop Stronger Documentation for Better Coding with MDCodePro

The “inaccurate reporting of modifiers has the potential to put the brakes on payment for claims,” according to JustCoding News: Outpatient, “or have serious financial consequences if auditors uncover compliance problems.”

As is often the case in medical coding, one of the best ways you can guard against mistakes in using CMS billing modifiers is to ensure your documentation is as accurate and comprehensive as possible. And one of the best ways you can achieve that goal is by making MDCodePro a part of your practice.

Our coding methodology, validated by numerous audits, offers you a streamlined understanding of CMS billing regulations as well as an easy-to-use approach to documentation that supports the most accurate, compliant, and optimalcode for each office or inpatient visit. And our intuitive, step-by-step code generator gives you an even greater advantage, finding the optimal code for every patient encounter based on the information you provide.

Find out more about how MDCodePro can make your practice even more efficient and productive. Request further information by filling out this online form.

The post Costly Mistakes to Avoid When Using CMS Billing Modifiers appeared first on MDCodePro.

source https://mdcodepro.com/blog/cms-billing-modifiers/

How to Make Sure Your Practice Achieves Telemedicine Compliance

Telehealth is on the rise. Here’s what you need to know to keep pace.

It seemed like science fiction not long ago,n but telemedicine (or telehealth)—real-time, two-way communication between physicians and distant patients—is poised to reshape U.S. healthcare delivery, especially in rural and other underserved areas.

Granted, according to a 2017 study, 82% of consumers “are still largely unaware of how to access telehealth or whether their insurer will cover it.” But 55% of providers are “investing in telehealth to improve health outcomes.” Experts expect a 30% to more than 40% growth in telemedicine in coming years. Increasingly, you’ll need to ensure compliance with telemedicine regulations  as you do the guidelines for in-person patient visits.

Demand for telemedicine will only increase in the coming years, thanks to both expanding cellular connectivity and broadband internet in rural areas and recent and current telehealth legislation, including certain provisions in the Bipartisan Budget Act of 2018. Senator Brian Schatz, a longtime champion of federal telemedicine regulations, told the National Law Review the Act’s passage marks “the most significant [telehealth] changes ever made to Medicare law.” And in 2017, 34 states passed telehealth legislation—more evidence telemedicine is a rapidly growing practice area few providers can afford to ignore.

Because our mission at MDCodePro is helping you achieve maximum compliance and optimal reimbursement for your work, here’s a brief look at regulatory issues with telemedicine you need to know about in order to make it a productive and profitable part of your practice.

Making Sense of the What, Where, and Who of Telemedicine

CMS telemedicine regulations identify which services qualify for Medicare reimbursement, where they must be performed, and which providers may do so.

• Eligible services involve live audio and video.

With the exception of certain demonstration programs in Alaska and Hawaii, only live, interactive audio-video communication between providers and patients are eligible for Medicare reimbursement.

Formerly, “store-and-forward” services (transmitting data to physicians via secure email for later review) were not eligible for reimbursement. But as of January 1, 2018, CMS began reimbursing remote patient monitoring (RPM) services under CPT® code 99091. (New codes are being developed CPT is developing new codes that will describe RPM more accurately.)

• Eligible services begin at a qualified originating site.

Where is your patient located when he or she starts to receive the telehealth service you’re providing? Your answer determines the service’s originating site. Medicare will reimburse services from an originating site located outside a Metropolitan Statistical Area (MSA), as defined by the Census Bureau, or in a rural Health Professional Shortage Area (HPSA), where the Health Resources and Services Administration has identified provider shortages.

Originating sites meeting telemedicine compliance standards include physicians’ and practitioners’ offices, acute care and Critical Access Hospitals (CAHs), Rural Health Clinics and Federally Qualified Health Centers, hospital- or CAH-based renal dialysis centers, skilled nursing facilities, and community mental health centers. Until recently, a patient’s home could not count as an originating site; however, under the Bipartisan Budget Act, Medicare will now reimburse some services provided to ESRD dialysis patients and stroke patients in their homes.

• Eligible services are performed by qualified healthcare providers.

If you are a physician, physician assistant, nurse practitioner, clinical nurse specialist, nurse-midwife, certified registered nurse anesthetist, clinical psychologist, clinical social worker, or registered dietician or nutrition professional, you may be reimbursed for eligible telemedicine services you provide.

Use MDCodePro to Code E/M Visits in Compliance with elemedicine Regulations

At MDCodePro, we focus on coding evaluation and management (E/M) services because those services are the ones the majority of most practitioners most often provide. While telemedicine changes delivery methods, it doesn’t change an E/M visit’s basic elements.

“As long as you perform and document the elements of history, exam and decision-making (or time spent counseling),” Bill Dacey writes for Physicians Practice, “and document them the same as you would as if you were there—and meet the basic conditions of a telemedicine visit—then you have a billable evaluation and management visit.”

The coding methodology presented in our easy-to-understand video lecture series and at work in our simple-to-use code generator can help you achieve telemedicine compliance in your telemedicine coding, just as it helps you correctly and optimally code in-person office or hospital visits. Fill out this online form today and we will contact you to share how MDCodePro can help.

The post How to Make Sure Your Practice Achieves Telemedicine Compliance appeared first on MDCodePro.

source https://mdcodepro.com/blog/telemedicine-compliance/

How Will CMS Bundled Payment Programs Shape Your Coding?

Know the issues BPCI Advanced raises for how you claim reimbursement.

The way you’re reimbursed for the services you provide is changing.

Increasingly, fee-for-service (FFS) models are giving way to bundled payment models that reward the quality, not the quantity, of services—value over volume. They encourage providers to coordinate care across specialties and settings.

CMS bundled payment programs have also, according to agency data, proven financially rewarding for many participating providers. Modern Healthcare analyzed statistics from hospitals, for instance, and reported, “Nearly half the 799 participating facilities across the country—47.8%—received gain-sharing payments for meeting the bundled-payment program’s cost and quality targets” in April-December 2016.

As CMS introduces a new bundled payment program this year, we at MDCodePro offer a brief overview of it and its implications for your accurate, compliant, and revenue-generating medical coding.

The Basics of CMS BPCI and BPCI Advanced

The CMS Innovation Center allows Medicare and Medicaid “to test models that improve care, lower costs, and better align payment systems to support patient-centered practices.” In 2013, the Innovation Center introduced the Bundled Payments for Care Improvement Initiative (BPCI).

In this model, Medicare doesn’t pay BPCI participants separately for each service provided to treat a patient’s condition during a specific time period, or “episode of care.” Instead, as the Kaiser Family Foundation explains, “Medicare establishes a total budget for all services… If the episode’s spending on services is below budget, then the providers may share in Medicare savings; alternatively, if providers’ costs exceed the budget, then the providers may incur losses.”

BPCI Advanced builds on BPCI, featuring simplified requirements that, as Becker’s Hospital CFO Report notes, increase “risk for [provider] participants while reducing flexibility… It remains to be seen how attractive this more standardized program will be to providers.”

On the other hand, as Today’s Hospitalist reports, BPCI Advanced “qualifies as an advanced alternative payment model under MACRA. That means that participants are potentially eligible for alternative-payment bonuses” (although meeting the annual threshold of Medicare patients required to qualify for those bonuses may prove difficult).

BPCI Advanced adds three outpatient episodes to the 29 inpatient episodes already offered in BPCI:

1. Percutaneous Coronary Intervention (PCI) – a nonsurgical procedure, sometimes called coronary angioplasty, to open narrowed or blocked coronary arteries and improve blood flow to the heart
2. Cardiac Defibrillator (CD) – Specifically, an implanted CD to control irregular heartbeats, especially those that can cause sudden cardiac arrest
3. Back and Neck Surgical Procedures (except Spinal Fusion) –  Cervical and non-cervical as well as combined anterior posterior spinal fusion procedures are included among the inpatient episodes

According to CMS Administrator Seema Verma, BPCI Advanced marks “an important step in the move away from fee-for-service… Under this model, providers will have an incentive to deliver efficient, high-quality care.”

How do CMS Bundled Payment Programs Affect Medical Coding?

Some experts worry increased use of bundled payments will motivate unscrupulous practitioners to steer clear of “sick” patients whose care costs more, postpone coding complications that may raise the cost of care, or upcode patients to get larger payments. “Under any reimbursement model,” Dr. Terry Shih and colleagues write in the cardiovascular journal Circulation, “there are always ways to ‘game’ the system, and bundled payments are no different.”

Apart from these concerns, BCPI Advanced highlights the need to change current CPT® coding and billing guidelines. In 2013, Dr. Darrell Kirch, president of the Association of American Medical Colleges, wrote to the Senate Finance Committee about Medicare physician payment reform. Among other topics, he addressed the assumptions underpinning current CMS regulations: “The documentation requirements must change from supporting billing that is based
on individual level of effort (the current evaluation and management system) to supporting payment for care that is provided by a team and is expected to meet metrics related to quality and cost.”

But until such reform happens, what do responsible providers like you need to know about coding for bundled payments?

• Communicate with other providers.
  Because CMS’ bundled payment programs encourage continuity of care, it’s vital you establish and maintain open channels of communication with other providers (especially providers of rehabilitative services, as many patients need these after acute care). You’ll ensure your patients are receiving quality care, learn from colleagues, and pave the way for smooth gainsharing.
• Make coding education a priority.
  View reimbursement changes as an opportunity to learn. As health information management expert Laurie McBrierty writes for ICD10 Monitor, “The clock is ticking on your preparedness… Educate yourself now so your organization will be optimally prepared.” Plus, it never hurts to brush up on or master for the first time the basics of the coding and billing guidelines—especially CMS bundled codes already in use, such as transitional care codes.
• Refine your documentation practices.
  The more you learn about medical coding, the more you realize how critical accurate and thorough documentation really is. It will continue to be vital to success with bundled payment programs. The code selections included in the bundle must properly reflect a patient’s condition and all aspects of his or her treatment. Bundled payments, Dari Bonner writes for AHIMA, “incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible.”

Code Confidently in the Midst of Change with MDCodePro

Although CMS bundled payment programs are changing, certain elements of the coding, billing, and payment process won’t change, such as the crucial importance of strong documentation and the centrality of a complexity risk score in determining medical necessity.

You can rely on MDCodePro to both educate you about the fundamentals of medical coding and help you code your services for maximum accuracy, regulatory compliance, and revenue.

Ready to find out more? Please contact us online using this form.

The post How Will CMS Bundled Payment Programs Shape Your Coding? appeared first on MDCodePro.

source https://mdcodepro.com/blog/cms-bundled-payment-program/

Two “Do’s”, Two “Dont’s” for Handling a Medical Coding Audit

Find out four pointers for making it through your medical audit successfully.

The most recent GAO report concerning money the U.S. government improperly paid,  estimates Medicare Fee-for-Service spent about $36 million it shouldn’t have in FY 2017.

While that figure represents a 2.5% decrease—the lowest rate since 2013, in fact—it’s still an awful lot of money.

But what does this situation mean for you as a professional healthcare provider and not just a taxpayer? It means medical coding audits aren’t going away anytime soon.

What is the role of coding auditing in today’s healthcare system? The government audits providers to recoup lost money. But audits can also benefit medical practices like yours when approached the right way. They can help ensure your coding is as accurate as possible, which contributes to not only better patient outcomes but also less lost revenue for you.

How to Handle a Medical Coding Audit

At MDCodePro, our focus is equipping you to maximize your medical coding regulatory compliance all the time—not just when it’s too late and an audit is on the horizon. There are several proactive steps you should take to prepare for audits. But we do want to offer some “do’s” and “dont’s” for handling them in ways that can lead to the best result for you.

DO Respond to the Audit Notice Right Away.

An audit notification is no reason to panic, but you also don’t want to ignore the importance of a medical coding audit. As Barbara Rubel of Management Services Network told Diagnostic Imaging, if you don’t respond within the short time frame allowed, “there’s the automatic assumption that the RAC [Recovery Audit Contractor] is correct and they start taking your money back.”

Responding quickly works to your advantage. Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 keeps Medicare from recouping payments when providers request redetermination or reconsideration. “If you respond to the initial audit/overpayment request within the first 20 days to 30 days,” Angela Miller of Medical Auditing Solutions told Physicians Practice, “that will prevent the requirement for payments on extrapolation until the appeal process is complete.”

DO Retain Professional Legal Counsel.

Don’t face an audit without the guidance of a healthcare law expert. Attorneys with experience in this field can not only help you ensure you are complying with the law, but also may identify potential errors or oversights in the auditor’s determination.

According to Angela Miller, providers should use attorneys and consultants because Medicare payers “are becoming very tenacious, so hoping for the best in an audit is ‘naive.’” Legal professionals’ outside perspectives may also  spark “ideas for corrective action that would benefit the provider that could be implemented prior to submitting the first level audit.”

DON’T Assume the Auditor is Correct.

“If you think there is an error with the payer’s findings,” Dr. Dennis Mihale and colleagues write for the AAPC, “you have a right to appeal the decision and should do so, as appropriate.” If you think the auditor’s initial determination is incorrect, it may be in your best interests to say so.

As Sharon Easterling points out for AHIMA, “A provider who is clear, factual, and has documented evidence supporting its original claim can often use [the discussion] period to its benefit.” After the discussion period, the more formal, five-level Medicare Appeals Process may still be an option.

Auditors can be intimidating, but they can also be wrong—and often are, according to the Physicians Advocacy Institute. That organization cites an HSS OIG finding that “approximately 44% of all appealed RAC contractors’ [sic] findings of alleged overpayments are overturned at the third level of appeal.”

DON’T Submit More Information Than Asked For.

When an auditor’s request for documentation from your practice arrives, comply with it, but don’t go above and beyond. As Kimberly Huey writes for the AAPC, “it’s not generally a good idea to send more than what was specifically requested.”

Make sure what you provide during a medical record audit is not only complete but also legible; many auditors won’t bother trying to read illegible records, and that will hurt your cause. In addition, don’t alter the records you send. Innocent attempts at clarification could be seen as deliberate falsifications, as healthcare law attorney Abby Pendleton told Diagnostic Imaging, and could lead to license revocation.

Increase Accurate Documentation Before Audits with MDCodePro

One last “do” is a step you can take right now, before any audit notice ever comes: Strengthen your documentation, and consequently your medical coding, by making MDCodePro your go-to resource for finding the optimal CPT® code for each patient visit.

With a methodology validated in countless audits and proven to have increased hundreds of physicians’ annual revenue by an average of $30,000, the MDCodePro app combines a streamlined, straightforward education in CMS E/M coding essentials with a powerful but easy-to-use code generator. You’ll learn and apply your new understanding of the Medicare coding guidelines with confidence, achieving greater regulatory compliance, more comprehensive and accurate record-keeping, and receiving more of the reimbursement you’ve legitimately earned and documented.

Fill out this online form to get more information about how MDCodePro can support your efforts to get your documentation and coding right, so you emerge from medical coding audits with your records and revenue intact.

The post Two “Do’s”, Two “Dont’s” for Handling a Medical Coding Audit appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-coding-audit/