ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 6 of 10 Instructor: Paul Sherman, DC

Transcription

1 Online Continuing Education Courses ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 6 of 10 Instructor: Paul Sherman, DC Important Notice: This download is for your personal use only and is protected by applicable copyright laws. Its use is governed by our Terms of Service on our website (click on Policies on our website s side navigation bar). CONTENT AND DOCUMENTATION GUIDELINES (BULLETS) FOR E/M SERVICES SPECIFICALLY FOR MUSCULOSKELETAL EXAMINATION (SINGLE ORGAN SYSTEM): MUSCULOSKELETAL EXAMINATION: Constitutional: Measurement of any three of the following seven vital signs: 1. Sitting or standing blood pressure 2. Supine blood pressure 3. Pulse rate and regularity 4. Respiration 5. Temperature 6. Height 7. Weight Note: Observe general appearance of patient i.e.: development, nutrition, body habitus, deformities, attention to grooming etc. Cardiovascular: Consists of examination of peripheral vascular system by observation and/or palpation of any one of the following: (pulse, temperature changes, edema and varicosities). Lymphatic: Consists of palpation of at least one area of the lymph nodes in the neck, axilla, groin and/or other locations. Musculoskeletal: Examination of gait and station Examination of joints, bones, muscle/tendons of four of the six body areas 1

2 (Neck, Back, RUE, LUE, RLE, LLE) Assessment of body areas include the following criteria: Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions ROM with notation of any pain, crepitation or contracture Stability with notation of any dislocation, subluxation or laxity Muscle strength and tone noting any atrophy or abnormal movements Extremities: See sections musculoskeletal and skin. Skin: Documentation requires meeting four of the six body areas (Neck, Back, RUE, LUE, RLE, LLE) Assessment of body areas consists of the following: Inspection and/or palpation with notation of any scars, rashes, lesions, ulcers, etc. Neurological/Psychiatric: Assessment consists of the following: Evaluating mental status to include assessment of mood and affect i.e.; depression, anxiety, agitation Evaluating orientation to include time, place and person Test coordination/balance i.e.; finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, etc. Examination of DTR s and pathological reflexes i.e.; Babinski, Hoffman Sign Examination of sensation i.e.; touch, pinprick, vibration and proprioception HOW TO SELECT THE APPROPRIATE LEVEL OF E/M SERVICE: 1. Identify the category and subcategory of service: Category-office visit, hospital visit or consultation Subcategory-new vs. established patient 2. Determine extent of history: Problem focused history, expanded problem focused history, detailed history or comprehensive history. 3. Determine extent of examination: Limited, expanded, detailed or comprehensive examination. 4. Determine complexity of medical decision-making (MDM): Straight forward, low complexity, moderate complexity or high complexity medical decision making. 5. Determine nature of presenting problem: Minimal, self-limiting, low severity, moderate severity or high severity. 2

3 6. Select the appropriate level of E/M service based upon the following: New patient-3 key components Hx, examination and medical decision making, has to be met or exceed the guidelines to qualify for a particular level of E/M service Note: The lowest of the 3 key components determines the E/M code or it can be determined by time. Established patient-2 of the 3 key components Hx, examination and medical decision making, has to be met or exceed the guidelines to qualify for a particular level of E/M service. Note: The lower component of the top 2 key components determines the E/M code or it can be determined by time. 7. Assess Time: Time is considered the key component to qualify for a particular level of E/M service when counseling and/or coordination of care dominates > 50% of the physician/patient and/or family encounter. This would be a face-to-face meeting with the patient either counseling and/or coordinating care. Time spent reviewing records without the patient does not qualify. Time is always rounded down not up. MODIFIERS: Primarily used if the physician has to alter a typical procedure either up grading or down grading. In other words if something extra had to be done or something less than usual was done. MODIFIERS SPECIFIC FOR MEDICARE CODING: Note: Medicare has redefined modifier GA and it has also created a new modifier called modifier GX both of which became effective on 4/1/10, and are related to the advanced beneficiary notice (ABN). 1. MODIFIER GA: The new meaning for this modifier is a Waiver of Liability Statement Issued as required by Payer Policy This modifier should be used to report when a required ABN was issued for a covered service, which you believe may be denied as not medically necessary. It informs the patient they would be responsible for the charges incurred. It advises Medicare that the patient was informed of this and that an ABN is on file signed and dated by the patient. Medicare requires their specific ABN form be used to document these new requirements, which is available at Note: The new ABN form was released March 2017 and took effect on June 21, Two minor changes were made to the form i.e.: CMS put a statement on the form indicating that CMS does not discriminate in its programs and activities and indicated the date at the bottom of the form expires on 3/

4 2. MODIFIER GX: The meaning of this modifier is a Notice of Liability Issued, Voluntary Under Payer Policy This modifier should be used to specifically report when a voluntary ABN was issued for a non-covered service only. Special Note: Modifier GA, which is a notice of waiver of liability statement issued as required by payer policy should not be reported on the same line with any other liability-related modifier like Modifier GX. Modifier GX, which is a notice of liability representing a voluntary ABN being issued to the patient for non-covered services only should also not be reported on the same line with any covered service or liability related modifier like Modifier GA (waiver of liability) or GZ (item or service is not reasonable and necessary). However, modifier GX is allowed to be reported on the same line with modifiers that indicate beneficiary liability like Modifier GY (which indicates an item or service is statutorily non-covered) this includes any and all services performed by a chiropractor with the exception of spinal manipulation (CMT). 3. MODIFIER GY: Used when an item or service is statutorily non-covered. This would include any and all services performed by a chiropractic physician with the exception of spinal manipulation. 4. MODIFIER GP: Used when therapy services (PT) is performed. Indicates there is an appropriate plan of care and documentation is in the record that supports the medical necessity of the therapy services. Note: Modifier GY should always be used with modifier GP when reporting and performing therapy service (PT). 5. MODIFIER GZ: Used when the provider or supplier wants to indicate that an item or service is not reasonable and necessary. 6. MODIFIER AT: Effective 10/1/04. Used when the doctor provides acute or chronic active/corrective treatment. Indicates doctor has a treatment plan. Treatment plan must include treatment goals. Treatment goals should always be updated after each phase of care i.e.: 2, 4 or 6 week plans, etc. Without using this modifier treatment will be considered maintenance therapy and will be denied. Maintenance chiropractic treatment is not medically reasonable or necessary under the Medicare law. 4

5 7. MODIFIERS QB and QU: These modifiers are only used if the doctor practices in an area that Medicare determines to be a health care professional shortage area (HPSA) i.e.: QB (rural) underserved area. QU (urban) underserved area. ADDITIONAL MODIFIERS USED FOR OTHER THAN MEDICARE: 1. MODIFIER 21: Used when extra time is spent than would typically be required for the specific E/M service. Report modifier as follows: representing E/M code (new patient E/M detailed) 2. MODIFIER 25: Used when the physician needs to perform an E/M service in addition to the typical procedure/service performed that day by a CPT/CMT code, which goes above and beyond the pre and post operative care associated with the procedure that was performed. Report modifier as representing CMT code 1-2 regions and representing E/M code (established patient E/M expanded) 3. MODIFIER 26: Indicates that there is a physician component and a technical component i.e.: x-rays (the physician reads the film and the facility/technician takes the x-ray). If this is the case an example for reporting this type of service would be , which represents 2 views were taken of the lumbar spine by an x-ray technician and that a physician will be reading the x-rays. Note: If the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components separately. 4. MODIFIER 51: Used when the provider performs additional procedures other than E/M services during that day. If using modifier report as follows: representing CMT code 1-2 regions and representing EMS. 5. MODIFIER 59: Used when two procedures are similar, but are truly separate services independent from each other and are performed on the same day. Report modifier as follows: representing CMT code 1-2 regions and representing mobilization. Note: A muscle diagnosis must be designated/diagnosed with and a structural/joint diagnosis must be documented with the CMT code. BASIC UNDERSTANDING OF MEDICARE APPEALS PROCESS: BENEFITS OF THE APPEALS PROCESS: Good documentation usually significantly improves the appeals decisions Statistically 95% of all Medicare claims are reversed in the appeals process provided all 5

6 documentation requirements are met A positive appeals decision usually means less future denials 5 LEVELS TO THE APPEALS PROCESS: 1.Re-determination 2.Reconsideration 3.Administrative Law Judge 4.Appeals Council Review 5.Federal Court (Judicial Review) 1. Re-determination: Sent directly to the carrier and performed by the carrier No monetary limit to be met A copy of the explanation of benefits (EOB) and all medical records for the entire year should be forwarded Usually done within 4 months (120 days) from the initial date of denial on the EOB 2. Reconsideration: Sent to a Qualified Independent Contractor (QIC) performed by the QIC No monetary limit to be met Usually done within 6 months (180 days) from the date of the re-determination 3. Administrative Law Judge: Sent to HHS Office of Medicare Hearings and Appeals (OMHA) Performed by HHS OMHA Monetary minimum of $ Usually done within 2 months (60 days) from the date of the reconsideration 4. Appeals Council Review: Sent to the Departmental Appeals Board (DAB) Performed by the DAB No monetary limit to be met Usually done within 2 months (60 days) from the date of the Administrative law Judge decision 5. Federal Court (Judicial Review): Performed by the Federal Court through the contractor (QIC) Monetary minimum of $1, Usually done within 2 months (60 days) from the date of DAB decision Note: Additional information regarding Medicare appeals process: Questions should be directed to Medicare ( ). Medicare should be notified of the specific state you are calling from and you should request the specific mailing address and phone number for your state. Medicare beneficiaries also have the right to request an appeal. Beneficiaries have 120 days from the date the claim was processed to file an appeal. 6

7 Instructions for the patient are on the last page of the patients Medicare Summary Notice-explanation of benefits (EOB) 7