CBR201606: Modifiers 24 & 25 General Surgeons

Transcription

1 Stay Tuned for Webinar Audio dial-in: ; PIN: # For technical assistance, send to CBR201606: Modifiers 24 & 25 General Surgeons May 25, :00 P.M. ET

2 CBR201606: Modifiers 24 & 25 General Surgeons May 25, :00 P.M. ET CBR CPT codes, descriptors, and other data are copyright 2014/2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 2

3 Disclaimer 2 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. CBR

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 (LCDs) and Local Coverage Articles (LCAs) 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 CBR contents. 4

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

6 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 CBR

7 Webinar Objective Upon completion of this webinar, you should be able to: Demonstrate a general understanding of CBR201606: Modifiers 24 & 25 General Surgeons Comprehend the analytical methods used to develop the report Locate policy references and resources CBR

8 Sample CBR Provided for each topic CBR

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

10 CBR Focus Metrics: Percentage of services appended with modifier 24 Percentage of services appended with modifier 25 Average minutes per visit with and without modifiers 24 and 25 Total charges per beneficiary for E/M services CBR

11 Demographics 5,500 providers Medicare Fee-for-Service (FFS) claims data Billing patterns different from their peers CBR

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

13 Acronyms Code Description CERT CPT MPFS NCCI OEI OIG RAC ZPIC Comprehensive Error Rate Testing Current Procedural Terminology Medicare Physician Fee Schedule National Correct Coding Initiative Office of Evaluation and Inspections Office of Inspector General Recovery Audit Contractors Zone Program Integrity Contractor CBR

14 Coverage & Documentation Overview CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. CBR

15 CBR Topic Choice Topics for CBRs are chosen based on investigations and reports by various agencies: Office of Inspector General Comprehensive Error Rate Testing Recovery Auditors Zone Program Integrity Contractors MAC audits CBR

16 The Feds Top 10 According to the RAC Monitor: Global surgical period was one of the few E/M services included in the OIG Work Plans Documentation must detail why an E/M should be paid within the global period Providers should implement steps to prevent inadvertent reporting of post-op E/M services as separately payable when the patient is in a post-surgical status, and bill appropriately CBR

17 What is a Modifier? Per CPT Manual, modifiers: Provide the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code Are appended to CPT and HCPCS codes to add specificity Are two types: Level I (CPT ) and Level II (HCPCS) CBR

18 Modifier 24 Defined by CPT Per the CPT Manual: The physician or other qualified health professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service. CBR

19 Modifier 24 Used on unrelated E/M services which occur during the global period of a surgery or procedure Visit was not for any kind of complication or issue as a result of the surgery/procedure Purpose of the visit must be for something other than evaluating the wound, removing sutures, and discussing the prognosis of the condition CBR

20 Global Surgery Package Medicare approved amounts for procedures include payment for: Preoperative visits Intra-operative services Complications following surgery Postoperative visits Postsurgical pain management Supplies and miscellaneous services CBR

21 What Is Not Included? For major surgeries, the initial consultation or evaluation of the problem Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery Treatment for the underlying condition or an added course of treatment which is not part of a normal recovery from surgery CBR

22 What Else Is Not Included? Diagnostic tests and procedures Clearly distinct surgical procedures which are not re-operations or treatment for complications Treatment for postoperative complications requiring an operating room A second, more extensive, procedure is allowable Immunosuppressive therapy for organ transplants & chemotherapy Critical care services unrelated to the surgery CBR

23 Don t Use Modifier 24 When Patient has a surgical complication, unless the complication requires a return to the operating room Patient has a wound infection Patient is admitted to a SNF for a condition related to the surgery Patient is seen for suture removal/dressing change Postoperative period (10 or 90 days) is over CBR

24 First Diagnosis Field unspecified local infection of skin and subcutaneous tissue other postoperative infection disruption of external operation (surgical) wound post operative pain seroma complicating a procedure V45.89 post procedural status V58.32 encounter for removal of sutures CBR

25 Modifier 25 Defined by CPT Used to support 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 CBR

26 Minor vs Major Procedures Global period of 000 or 010 days: 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 Global period of 090 days: Major surgical procedure CBR

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

28 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 CBR

29 Global Periods Global Fee Period Explanation 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) CPT codes and descriptors are copyright 2014/2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. CBR

30 Correct Use of Modifier 25 Patient was evaluated for treatment of knee pain and gout: Corticosteroids were administered to the knee joint CPT code 20610: arthrocentesis, aspiration, or injection of major joint or bursa (000 global days) Patient was also evaluated for new onset of gout and meds were prescribed CPT code : evaluation and treatment of gout CBR

31 Supporting 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 CBR

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 CPT codes and descriptors are copyright 2014/2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. CBR

33 Methods & Results CPT codes, descriptors, and other data only are copyright 2014/2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. CBR

34 Report Data Medicare Part B Rendering Provider By National Provider Identifier (NPI) CPT codes: Peer groups Used for comparison with the individual providers CBR

35 Peer Groups State Medicare providers in the provider s state E/M codes National All Medicare providers in the nation with E/M codes CBR

36 Data Source CMS Integrated Data Repository (IDR) Extracted: February 18, 2016 Dates of Service: October 1, 2014 September 30, 2015 CBR

37 Table 1 CPT Abbreviated Description Typical Time Minimal Problem/Exam 5 Minutes Problem Focused/Exam 10 Minutes Expanded Problem Focused/Exam 15 Minutes Detailed Patient History/Exam 25 Minutes Comprehensive Patient History/Exam 40 Minutes CPT codes and descriptors are copyright 2014/2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. CBR

38 Table 2 Table 2: Summary of Your Utilization for E/M CPT Codes and Modifiers 24 & 25 October 1, 2014 September 30, 2015 Allowed Allowed Beneficiary CPT Modifier Charges Services Count $ $ Neither $ $ $ Neither $ $ $5, Neither $15, $ $1, Neither $7, $ $ Neither $ TOTAL $29, CBR

39 Understanding Table 2 Table 2: Summary of Your Utilization for E/M CPT Codes and Modifiers 24 & 25 October 1, 2014 September 30, 2015 CPT Modifier Allowed Allowed Beneficiary Charges Services Count $ $ Neither $ $ $ Neither $ $ $5, Neither $15, $ $1, Neither $7, $ $ Neither $ TOTAL $29, CBR

40 Comparison Outcomes There are four possible outcomes: Significantly Higher Higher Does Not Exceed N/A CBR

41 Percentage of Services with Modifier 24 and 25 Calculated as follows: Number of Services with Modifier Total Number Services X 100 CBR

42 Table 3 Table 3: Percentage of Services with Modifier 24 and 25 October 1, 2014 September 30, 2015 Modifier Your Percentage of Modifier Use Your State s Percentage of Modifier Use Comparison with Your State s Average National Percentage of Modifier Use Comparison with the National Percentage 24 0% 3% Does Not Exceed 3% Does Not Exceed 25 23% 10% Significantly Higher 11% Significantly Higher A chi-square-test was used in this analysis, alpha = CBR

43 Calculating Percentage of Services with Modifier 24 and 25 Table 2: Summary of Your Utilization for E/M CPT Codes and Modifiers 24 & 25 October 1, 2014 September 30, 2015 CPT Modifier Allowed Allowed Beneficiary Charges Services Count $ $ Neither $ $ $ Neither $ $ $5, Neither $15, $ $1, Neither $7, $ $ Neither $ TOTAL $29, CBR

44 Calculating Percentage of Services with Modifier 24 and 25 (cont.) Number of Services with Modifier Total Number Services X = % CBR

45 Calculating Average Allowed Minutes per Visit by Modifier Calculate a Total Weighted Services by Modifier Designation 1. Separate claim lines by those with/without modifiers 24 and Assign value to each CPT code by typical minutes 3. Multiply assigned value with number of services 4. Combine the products from each CPT code calculation CBR

46 Average Allowed Minutes per Visit by Mod 24, Mod 25 and Neither Mod Calculated as follows: Total E/M Weighted Services by Modifier Designation Total Number of E/M Visits by Modifier Designation CBR

47 Table 4 Table 4: Average Allowed Minutes per Visit with Mod 24, Mod 25 and Neither Mod October 1, 2014 September 30, 2015 Modifier Your Average Minutes per Visit Your State s Average Minutes per Visit Comparison with Your State s Average National Average Minutes per Visit 24 N/A N/A N/A Comparison with the National Percentage Does Not Exceed Does Not Exceed Neither Higher Higher A t-test was used in this analysis, alpha = CBR

48 Calculating Average Allowed Minutes per Visit by Modifier (cont.) Table 2: Summary of Your Utilization for E/M CPT Codes and Modifiers 24 & 25 October 1, 2014 September 30, 2015 CPT Modifier Allowed Allowed Beneficiary Charges Services Count $ $ Neither $ $ $ Neither $ $ $5, Neither $15, $ $1, Neither $7, $ $ Neither $ TOTAL $29, CBR

49 Equation for Calculating Average Allowed Minutes per Visit by Modifier Total E/M Weighted Services by Modifier Designation Total Number of E/M Visits by Modifier Designation 0 5 mmmm mmmm mmmm mmmm mmmm CBR

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

51 Table 5 Table 5: Average Allowed Charges per Beneficiary October 1, 2014 September 30, 2015 Your Average Allowed Charges per Beneficiary Your State s Average Allowed Charges per Beneficiary Comparison with Your State s Average National Average Allowed Charges per Beneficiary Comparison with the National Average Charges $ $ Significantly Higher $ Does Not Exceed A t-test was used in this analysis, alpha = CBR

52 Calculating the Average Allowed Charges per Beneficiary Table 2: Summary of Your Utilization for E/M CPT Codes and Modifiers 24 & 25 October 1, 2014 September 30, 2015 CPT Modifier Allowed Allowed Beneficiary Charges Services Count $ $ Neither $ $ $ Neither $ $ $5, Neither $15, $ $1, Neither $7, $ $ Neither $ TOTAL $29, CBR

53 Calculating the Average Allowed Charges per Beneficiary (cont.) Calculated as follows: Total Allowed Charges Total Number of Beneficiaries or CBR

54 References References & Resources Resources CPT codes, descriptors, and other data only are copyright 2014/2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. CBR

55 Claims Processing Manual Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners Section Selection of Level of Evaluation and Management Service Section Payment for Evaluation and Management Services Provided During Global Period of Surgery Section Surgeons and Global Surgery CBR

56 NCCI Policy Manual National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services (rev. January 2014), Chapter 1 General Correct Coding Policies Section C Medical/Surgical Package Section D Evaluation and Management (E&M) Services Section E Modifiers and Modifier Indicators CBR

57 Medicare Learning Network (MLN ) Global Surgery Fact Sheet, ICN /August 2013 Guidance to Address Billing Errors, Medicare Quarterly Provider Compliance Newsletter, Volume 1, Issue 2, ICN /February 2011 How to Use the Searchable Medicare Physician Fee Schedule (MPFS), ICN , January 2016 CBR

58 Office of Inspector General (OIG) Work Plan Fiscal Year 2010 Evaluation and Management Services During the Global Surgery Periods Work Plan Fiscal Year 2012 Evaluation and Management Services, use of Modifiers During the Global Surgery Period (New) Work Plan Fiscal Year 2013 Evaluation and Management Services During Global Surgery Period Use of Modifier 25, OEI CBR

59 Additional Resources Wisconsin Physician Services Health Insurance Modifier 24 Fact Sheet American College of Surgeons Documentation of Services Provided in the Postoperative Global Period, May 2013 CBR

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

61 FAQs General FAQs CBR Specific FAQs CBR201606: Modifier 24 & 25 General Surgeons CBR

62 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 CBR

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66 Questions & Answers CBR

67 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 CBR