CBR Modifier 25: Otolaryngologists

Transcription

1 Stay Tuned for Webinar Audio dial-in: ; PIN: # For technical assistance, send to CBR Modifier 25: Otolaryngologists Begins at 3:00 P.M. ET

2 CBR Modifier 25: Otolaryngologists CPT codes, descriptors, and other data are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 2

3 The CBR project has made every reasonable effort to ensure the accuracy of the information and web links provided in the CBR materials at the time of publication; however, Medicare policy changes frequently, so the information and links within the material may change without further notice. It is the responsibility of the provider to remain up-to-date with Medicare Program requirements. 3

4 CBR materials are prepared as a service to the public and are not intended to grant rights or impose obligations. The information provided in the CBR material is only intended to be a general summary. It does not supersede or alter the coverage and documentation policies outlined in the local coverage determinations (LCD) and policy articles for the A/B Medicare Administrative Contractors (MAC) or DME Medicare Administrative Contractors (DME MAC). Please refer any specific questions you may have to the A/B or DME MAC for your region. We encourage providers to review the specific statutes, regulations, and other interpretive material for a full and accurate statement of their contents. 4

5 Webinar Outline 1. Introduction 2. Coverage & Documentation Overview 3. Methods & Results 4. References & Resources 5. Q&A 6. Survey 5

6 Webinar Requirements Landline for conference call (cell phones are not recommended) Wired (not wireless) broadband internet connection Not Recommended: Access Points/Mobile Air Connections PC computer using Windows or MAC operating system Android or ipad tablets Latest version of Adobe Flash installed 6

7 Webinar Protocol All attendee lines are muted Submit questions via chat when prompted by speaker Submit questions during the Q&A session at the end of webinar Ask questions pertinent to webinar Contact MAC for specific claims questions 7

8 Webinar Objective Upon completion of this webinar the participant should be able to: Demonstrate a general understanding of CBR Modifier 25: Otolaryngologists Comprehend the analytical methods used to develop the report Locate policy references and resources 8

9 Sample CBR Provided for each topic 9

10 CBR Purpose Designed to: Provide education to the provider community Compare billing practices among Medicare providers and their peer groups Gives providers an opportunity to: Check their records against data in CMS files Review Medicare guidelines to ensure compliance 10

11 CBR Focus Percentage of claim lines with modifier 25 appended Average allowed minutes per visit for lines with and without modifier 25 appended Average allowed charges per beneficiary, per year 11

12 Demographics 5,000 providers Medicare Fee-for-Service (FFS) claims data Billing patterns different from their peers 12

13 Webinar Materials References and Resources Webinar slides MP4 of webinar Webinar Handout Webinar Q&A Handout 13

14 Acronyms Code CERT CPT MPFS NCCI OEI OIG PTP RAC Description Comprehensive Error Rate Testing Current Procedural Terminology Medicare Physician Fee Schedule National Correct Coding Initiative Office of Evaluation and Inspections Office of Inspector General Procedure-to-Procedure Recovery Audit Contractors 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. 14

15 Coverage & Documentation Overview 15

16 E/M Claims with Modifier 25 Improper Payments = $538 Million 35 /o of Services Provided 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. 16

17 Review of Claims: Modifier 25 Did Not Respond to Request - 3% \ Missing Identifying ( Information - 4% "'( ~ Met Requirements - 64% Failed to Document E/M Service and/or Procedure - 27% 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. Use of Modifier 25, OEI , November 2005 Failed to Meet Modifier 25 Requirements - 2 /o 17

18 2002 Allowed Claims Appended with Modifier 25 cu U) ::::, t,a U) U) cu u cu c ::::, Number of Claims Submitted with Modifier ,608 7 million 8.8 million 8.9 million Provider's Use of Modifier 25 on Claims Submitted 100 /o /o /o 1-19 /o 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. Use of Mod1fie1 25, OEI , November 2005 cu U) ::, I. cu CL 0 I

19 Other Investigations New York State, Office of the State Comptroller United HealthCare: Certain Claim Payments for Evaluation and Management Services, April 2012, Report 2010 S 67 Audited: New York State Health Insurance Program claims Results: 12.6% did not meet requirements for appending the 25 modifier 19

20 False Claims Act The United States Attorney s Office, Northern District of Georgia Leading Oncology Practice to Pay $4.1 Million to Settle False Claims Act Investigation, Press Release: September 19, 2012 Settlement with Georgia Cancer Specialists I, PC 27 offices in Atlanta metro area $4.1 million for violations of the False Claims Act 20

21 What is a Modifier? Provide the means to report that a service or procedure performed has been altered by some circumstance but not changed in its definition or code Append to CPT and Healthcare Common Procedure Coding System (HCPCS) codes to add specificity Level I (CPT ) Level II (HCPCS) 21

22 Modifier 25 Indicates a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service 22

23 Surgical Package Always includes: Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical) Immediate post-operative care, writing orders, post anesthesia care and routine follow-up 23

24 Minor Procedures Global period of 000 or 010 days: a minor surgical procedure In general, E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure Example: removal of a foreign body from a muscle or tendon sheath; simple 24

25 Major Procedures Global period of 090 days: defined as a major surgical procedure Evaluation and management services performed on the same day as the procedure are payable, when reported with modifier 57, if the E/M was done in order to determine the need for the surgery Example: total hip replacement 25

26 Medicare Physician Fee Schedule Database (MPFSDB) Instructions: 26

27 Determine the Global Period Medicare Physician Fee Schedule Database: 1. Select Physician Fee Schedule Search, system defaults to current year 2. Under Type of Information select Payment Policy Indicators 3. Choose a single code/multiple codes/code range then enter the appropriate code(s) 4. Select a modifier or All Modifiers 5. Refer to the column heading Global 27

28 Global Periods 000 Zero Global Days 010 Ten Global Days 090 Ninety Global Days xxx yyy zzz MMM Global Concept Does Not Apply Defined by A/B MAC Related to Another Procedure Maternity Codes (Usual Global Period Does Not Apply) 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. 28

29 Modifier 25: Correct Use The patient was evaluated for treatment of neck pain and insomnia: Trigger point injections were administered to three muscles for neck pain CPT code 20553: trigger point injections (000 global days) The patient was also evaluated for new onset of insomnia and meds were prescribed CPT code : evaluation and treatment of insomnia 29

30 Modifier 25: Incorrect Use The patient was seen for a second appointment for a non-healing wound: Physician debrided the skin and subcutaneous tissue CPT code only No other conditions were addressed Documentation reflected only the physician s time, examination and medical decision making to determine the need for the debridement Do not submit CPT code

31 Documentation Auditors should be able to see the additional work that was involved Documentation must support: History Exam Knowledge Work time Risk Above and beyond what is usually required for the surgery or procedure 31

32 Time Allowed per Visit CPT Code Typical Time Presenting Problem Minutes Minimal problem Minutes Self-limited or minor Minutes Low to moderate severity Minutes Moderate to high severity Minutes Moderate to high severity 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. 32

33 Use of Time to Determine the Level of E/M Service When counseling and/or coordination of care dominate (more than 50%) of the time a physician spends with a patient during an evaluation and management (E/M) service then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. Proper documentation must be in the patient s medical record 33

34 Methods & Results 34

35 Report Data Medicare Part B Rendering Provider By National Provider Identifier (NPI) Specialty 04 (Otolaryngology) CPT codes Peer groups Used for comparison with the individual providers 35

36 Peer Groups State: Medicare providers in the provider s state E/M codes Specialty of 04 National: All Medicare providers in the Nation E/M codes Specialty of 04 36

37 Data Source CMS Integrated Data Repository Extracted: July 29, 2015 DOS: April 1, 2014 March 31,

38 Table 1 Table 1: CPT Codes, Abbreviated D escriptions, and Typical Times CPT Abbreviated Description Ty pical Time l[inimal Problem/ Exam 5 finutes Problen1 Focu ed/ Exam 10 Iinutes Expanded P roblein Focused/ Exam ] 5 1\ f inutes Detailed Patient Hi tory / Exam 25 l\iinute Comprehensive Patient History / Exam 40 l\iinutes 38

39 Table 2 Table 2: Summary of Your Utilization for E / M Codes and Modifier 25 April 1, March 31, 2015 Allowed Allowed Beneficiary CPT Type Charges Services Count With Modifier 25 $ Without :Modifier 25 $ vvith Modifier 25 $ vvithout :Modifier 25 $ With Modifier 25 $1, \i\tithout 1odifier 25 $5, vvith Modifier 25 $1, vvithout :Modifier 25 $24, With Modifier 25 $3, vvithout 1odifier 25 $13, TOTAL $50,

40 Understanding Table 2 Table 2: Summary of Your Utilization for E / M Codes and Modifier 25 April 1, March 31, 2015 Allowed Allowed Beneficiary CPT Type Charges Services Count With Modifier 25 $ Without :Modifier 25 $ vvith Modifier 25 $ vvithout :Modifier 25 $ With Modifier 25 $1, I \i\tithout :Modifier 25 $5, vvith Modifier 25 $1, vvithout rviodifier 25 $24, With Modifier 25 $3, vvithout 1odifier 25 $13, TOTAL $50,

41 Comparison Outcomes There are four possible outcomes: 1. Significantly Higher 2. Higher 3. Does Not Exceed 4. N/A 41

42 Percentage of Services Calculated as follows: with Modifier 25 Nun1ber of Services with Modifier 25 Total N un1ber of Services xloo 42

43 Table 3 J\Iod 25 Table 3: Percentage of Services with Modifier 25 April 1, March 31, 2015 Your Your State's National Percentage of Percentage Comparison with Percentage Modifier 25 of Modifier Your State's of Modifier Use 25 Use Percentage 25 Use 13% 46% Does Not Exceed 45% Comparison with the National Percentage Does Not Exceed 43

44 Calculating the Percentage of Services with Modifier x % 44

45 Calculating Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25 Calculate a total weighted services by visit 1. Separate claim lines by those with and without modifier Assign value to each CPT code by typical minutes 3. Multiply assigned value with number of services 4. Visits with multiple claims are combined 45

46 Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25 Calculated as follows: ( Total E/M Weighted Services by Modifier Designation) Total Number of E/M Visits by Modifier Designation 46

47 Table 4 Type With Iod 25 Without i\iod 25 Table 4: Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25 April 1, March 31, 2015 Your Your State's National Average Average Comparison with Average Minutes Minutes Your State's Minutes Per Visit Per Visit Average Per Visit Significantly Higher Significantly Higher Comparison with the National Average Significantly Higher Significantly Higher 47

48 Average Allowed Charges Calculated as follows: per Beneficiary Total Allowed Charges Total Number of Beneficiaries 48

49 Table 5 Charges Table 5: Average Allowed Charges p er Ben eficiary April 1, March 31, 2015 Your Your State's National Average Average Comparison with Average Charges Per Charges Per Your State's Charges Per Beneficiary Beneficiary Average Beneficiary $ $ Higher $ Comparison with the National Average Significantly Higher 49

50 Calculating Average Allowed Charges per Beneficiary $50, $

51 References & Resources 51

52 Claims Processing Manual Medicare Claims Processing Manual, Chapter 12 Physician/Non-physician Practitioners Section Selection of Level of Evaluation and Management Service Section Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Section Payment for Evaluation and Management Services Provided During Global Period of Surgery Section Surgeons and Global Surgery 52

53 NCCI Policy Manual National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Revision Date: January 01, 2014 Chapter I General Correct Coding Policies Section D Evaluation and Management (E&M) Services Section E Modifiers and Modifier Indicators 53

54 ACP Internist & OIG Report ACP Internist Learn Proper Coding for Modifiers 59 and 25, July/August Office of Inspector General Use of Modifier 25, November 2005, OEI

55 Additional Resources Medicare Learning Network, Global Surgery Fact Sheet, ICN907166, August MLN/MLNProducts/downloads/GloballSurgery-ICN pdf American Association of Family Practice Understanding When to Use Modifier 25 American Medical Association, CPT 2013 Professional Edition Manual CPT Assistant

56 CBR Website About Us CBR Releases CBR Support Education Recommended Links FAQs Contact Us 56

57 FAQs General FAQs CBR Specific FAQs CBR Modifier 25: Otolaryngologists Delivenng Value, Achieving Results ego PALMETTO GBA Home Al:x>ut Us CBR Support contact Us ( Comparative Billing Reports CBR FAQs < > Most Recent CBR 57

58 Provider Self-audit Providers and suppliers have an obligation to ensure claims are submitted to Medicare correctly Self-audits allow providers and suppliers to identify coverage and coding errors Refer to the following CBR sections for assistance Documentation and Billing References 58

59 CBR Support Help Desk Monday Friday: 9:00 a.m. to 5:00 p.m. ET Toll Free cbrsupport@eglobaltech.com 59

60 Contacting MACs Providers should contact the Medicare Administrative Contractor (MAC) for assistance with: Claim Information Documentation Requirements Billing and Coding 60

61 NPPES National Plan & Provider Enumeration System Source for mailing address used for the CBR Correct your mailing information at 61

62 Questions & Answers 0 62

63 We make every effort to address all questions submitted during our webinars. However, we cannot provide responses related to coding issues or to specific claims/scenarios. Since your Medicare Administrative Contractor (MAC) makes the determination to pay or deny a claim based on the CPT codes, medical documentation and description of the circumstances, and we do not have access to this documentation, we cannot respond to these types of questions. Please contact your MAC with questions that we do not address or if you identify any claims discrepancies while reviewing your CBR. The contact information for your MAC is located at 63