CBR Modifier 25: Nurse Practitioners

Transcription

1 Stay Tuned for Webinar Audio dial-in: ; PIN: # For technical assistance contact CBR Modifier 25: Nurse Practitioners Begins at 3:00 P.M. ET

2 CBR Modifier 25: Nurse Practitioners 2

3 Disclaimer Paragraph 1 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 Disclaimer Paragraph 2 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. Next Steps 6. Contact Information 7. Q&A 8. Survey 5

6 Webinar Requirements Landline for conference call (cell phones are not recommended) Wired (not wireless) broadband internet connection 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 the CBR for Modifier 25: Nurse Practitioners (50) 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 Focus This CBR examines: Percentage of claim lines with modifier 25 appended Average allowed minutes per visit for claim lines with and without modifier 25 Average allowed charges per beneficiary, summed for the one-year period, regardless of the modifier appended CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 11

12 Demographics 7,500 Nurse Practitioners Data from claims paid by traditional Fee For Service (FFS) Medicare Billing patterns different from their peers 12

13 Webinar Materials References and Resources Webinar slides MP4 of webinar Webinar Handout Webinar Q&A Handout Recommended Links: Resources from event: 13

14 Acronyms CERT: Comprehensive Error Rate Testing CPT: Current Procedural Terminology MPFS: Medicare Physician Fee Schedule NCCI: National Correct Coding Initiative OEI: Office of Evaluation and Inspections OIG: Office of Inspector General PTP: Procedure-to-Procedure RAC: Recovery Audit Contractors 14

15 Coverage & Documentation Overview 15

16 Topic Selection Office of Inspector General (OIG) Use of Modifier 25, OEI , November 2005 Medicare requirements not met: 35% of services Improper payments: Estimated at $538 million In 2002, Medicare allowed $1.96 billion for approximately 29 million claims billed 16

17 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: Results: New York State Health Insurance Program claims 12.6% did not meet requirements for appending the 25 modifier 17

18 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 18

19 What is a Modifier? Provide the means to report or indicate that a service or procedure performed has been altered by some circumstance but not changed in its definition or code Append CPT and Healthcare Common Procedure Coding System (HCPCS) codes to add specificity Level I (CPT ) Level II (HCPCS) CPT 2013 Professional Edition, available from HCPCS Level II Standard Edition, available from 19

20 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 American Medical Association: solutions-managing-your-practice/coding-billing-insurance/cpt.page 20

21 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 CPT Assistant Articles: 21

22 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 22

23 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 23

24 Medicare Physician Fee Schedule Database (MPFSDB) Instructions: fee-schedule/help/medicare Physician-Fee-Schedule-Search Help.pdf 24

25 Determine the Global Period Medicare Physician Fee Schedule Database: 1. Select Physician Fee Schedule Search Screen 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 25

26 Global Periods 26

27 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 CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 27

28 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 CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 28

29 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 29

30 American Academy of Family Physicians (AAFP) Key components of a problem-oriented E/M service for complaint/problem must be documented Problem/complaint must stand alone to be a billable service Different diagnosis is not required If same diagnosis, documentation must support extra work above and beyond pre- or post-operativ e work associated with procedure Understanding When to Use Modifier 25: 30

31 IPPE or AWV on Same Day as an E/M Service IPPE ( Welcome to Medicare visit) or AWV: Modifier 25 is not appended No part of the IPPE or AWV documentation can be used toward the medically necessary E/M Additional E/M service: Modifier 25 is appended to the additional E/M service 31

32 Time Allowed per Visit 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 American Medical Association, CPT 2013 Professional Edition: productdetail.jsp?product_id=prod &sku_id=sku &navaction=push 33

34 Methods and Results 34

35 Report Data Medicare Part B Rendering Provider Located by National Provider Identifier (NPI) Specialty 50 (Nurse Practitioners) CPT codes Peer groups For comparison with the individual providers 35

36 Peer Groups State Medicare providers in the provider s state E/M codes Specialty of 50 National All Medicare providers in the nation E/M codes Specialty of 50 36

37 Data Source CMS Integrated Data Repository (IDR) Extracted: January 26, 2015 Dates of Service: July 1, 2013 June 30,

38 Table 1 CPT Codes, Abbreviated Descriptions, and Typical Times CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 38

39 Table 2 Summary of Your Utilization for E/M Codes and Modifier 25 July 1, 2013 June 30, 2014 CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 39

40 Understanding Table 2 Summary of Your Utilization for E/M Codes and Modifier 25 July 1, 2013 June 30, 2014 CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 40

41 Comparison Outcomes Four possible outcomes: 1. Significantly Higher 2. Higher 3. Does Not Exceed 4. Not Applicable (N/A) 41

42 Percentage of Claim Lines Calculated as follows: with Modifier 25 42

43 Table 3 Percentage of Claim Lines with Modifier 25 July 1, 2013 June 30,

44 Calculating Percentage of Claim Lines with Modifier 25 Summary of Your Utilization for E/M Codes and Modifier 25 July 1, 2013 June 30,

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

46 Average Allowed Minutes per Visit with/without Modifier 25 Calculated as follows: 46

47 Table 4 Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25 July 1, 2013 June 30,

48 Average Allowed Charges Calculated as follows: per Beneficiary 48

49 Table 5 Average Allowed Charges per Beneficiary July 1, 2013 June 30,

50 Calculating Average Allowed Charges per Beneficiary Summary of Your Utilization for E/M Codes and Modifier 25 July 1, 2013 June 30,

51 References & Resources 51

52 Medicare Claims Processing Manual Selection of Level of Evaluation and Management Service Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Payment for Evaluation and Management Services Provided During Global Period of Surgery 40.1 Definition of a Global Surgical Package 40.2 Billing Requirements for Global Surgeries Medicare Claims Processing Manual, Publication Chapter 12 Physician/Non-physician Practitioners: index.html?redirect=/nationalcorrectcodinited/ 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 NCCI Policy Manual for Medicare Services: index.html?redirect=/nationalcorrectcodinited/ 53

54 OIG & CMS Resources Use of Modifier 25, Office of Evaluation and Inspections, OEI , November HHS OIG Work Plan: FY Plan-2012.pdf HHS OIG Work Plan: FY 2013 oig.hhs.gov/reports-and-publications/archives/workplan/2013/work-plan 2013.pdf Global Surgery Fact Sheet, Medicare Learning Network, ICN , March MLN/MLNProducts/downloads/GloballSurgery-ICN pdf 54

55 Additional Resources Felger, Thomas A., MD and Marie Felger. Understanding When to Use Modifier 25. Family Practice Management, October American Medical Association CPT 2013 Professional Edition CPT 2012 Professional Edition 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: Nurse Practitioners 57

58 Next Steps 58

59 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 59

60 Contact Information 60

61 CBR Support Help Desk Monday Friday: 9:00 a.m. to 5:00 p.m. ET Toll Free cbrsupport@eglobaltech.com 61

62 Contacting MACs Providers should contact the Medicare Administrative Contractor (MAC) for assistance with: Claim Information Documentation Requirements Billing and Coding Locate Your MAC: Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/ 62

63 NPPES National Plan & Provider Enumeration System Source for mailing address used for the CBR Correct your mailing information at 63

64 Questions & Answers 64

65 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 65