Bill Dacey

A “bold proposal” to reduce the documentation burden on physicians was released as part of CMS’s 2019 proposed Medicare Physician Fee Schedule (PFS). This seemed to have begun as an effort to listen to stakeholders and address the problems of out-of-date guidelines, cloning, EHR misuse, and problems that have evolved since the inception of the documentation guidelines. However, this proposal introduces a wholly self-serving and uninvited component of a change to payment rates and methodology that no one asked for.

The catchy tagline of “Patients over Paperwork” implies a quality issue caused in part by administrative overkill, but let’s not forget that these are the federal guidelines that have been enthusiastically enforced for more than 20 years by this same CMS.

Last year, when CMS sought input from stakeholders about the need to reduce the documentation burden caused by “administratively burdensome and outdated” guidelines-their own words-the decision was hailed within the industry.

 CMS had said, “We are … specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels.” The agency went on to say that, “We believe medical decision-making and time are the more significant factors in distinguishing visit levels and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties.”

No argument there. Physicians have been looking forward to the results of the comment period and hoping for some regulatory relief.

CMS didn’t say, “While we’re at it, let’s change the way providers are paid. Let’s find a way to pay providers less, particularly for the most complex patients.” But that’s exactly what they’ve done with this new proposal.

Last month, CMS administrators and physician leadership from the offices of Health Information Technology and Center for Medicare and Medicaid Innovation (CMMI) gathered for a telecast promoting “Patients over Paperwork,” or their E/M coding reform.

Touting their heartfelt desire to reduce documentation burdens and save individual physicians 51 hours a year in documentation time (roughly an hour a week), these former practicing physicians went on to give some real examples of how the current documentation guidelines don’t work well in the EHR environment, which was also mandated by CMS, if you recall.

Side note: Adam Boehler, CMS deputy administrator and director for the CMMI made an interesting comment that in the next couple of years, everyone’s EHR will be available on your phone. Heads up, HIPAA.

It’s true that it’s difficult to find the real information in an over-templated note, and this could be a danger to patients. It’s a little less true that docs can’t write real notes. Docs don’t-or won’t is more like it-but some EHRs don’t make it easy, either. 

The first part of the proposal is directed at the real issue: the documentation burden. The proposal states, “We propose to apply a minimum documentation standard where, for the purposes of PFS payment for an office/outpatient E/M visit, practitioners would only need to meet documentation requirements currently associated with a level 2 visit for history, exam and/or medical decision-making (except when using time to document the service).”

The proposed rule doesn’t specify what level 2, new or established, but let’s assume established since most visits are established. That’s a surprising choice since the documentation burden is so low-no reviews of system (ROS), one exam element, and subacute decision-making.

A 99213 is the most widely reported E/M code and is generally recognized to represent one unit of provider work, an acute uncomplicated problem, or a stable chronic illness. It is somewhat surprising to see, then, that the documentation level wasn’t set there, since it is still very easy to achieve without “note bloat.” But perhaps that is intended as more of the bait, because here comes the switch. Cue the theme music from the Paul Newman and Robert Redford movie 

CMS writes: ‘‘We believe our proposed documentation changes for E/M visits are intrinsically related to our proposal to alter PFS payment for E/M visits. … We are proposing to create a single rate under the PFS that would be paid for services billed using the current CPT codes for level 2 through 5 E/M visits. It would not be material to Medicare’s payment decision which CPT code (of levels 2 through 5) is reported on the claim.”

Yes, you read that right. Now that we have reduced the documentation burden for all E/M levels within a code category to a level well below what most codes report and require, it doesn’t matter what code you pick. CMS will pay you the same amount.

Somehow, documentation reduction has now introduced payment consolidation and in many, if not most cases, payment reduction for some providers. This is not an unintended consequence. This is calculated and deliberate.

The rest of the proposal dealing with E/M goes on to say that you can use a time basis to select your code, MDM, or even the old 1995 and 1997 guidelines as the basis for your code selection. The point is, it no longer matters what codes you choose because get paid the same.

CMS will likely find that providers lose interest pretty quickly in coding and documentation once it is uncoupled from payment. What they had been complaining about, justifiably, was the time it took to document, not to code. Half of the documentation issue is on EHR’s themselves and their ease of use, or lack thereof.

Were this proposal to be passed as is, it could result in some real unintended consequences. The first provider to comment on this to me said, “Fine, if you make all the visit and payments the same, I’ll just fire all my complex patients.” There’s a consequence. It’s probably not the majority view, but it’s one that CMS should have considered.

We won’t get into the CMS bad math behind the assertion that change in payment methodology amounts to a 1 or 2 percent change in revenues. For some specialties, the loss in the E/M revenue is in double digits, clearly a significant cut.  The specialty societies will no doubt follow-up with some projected numbers very shortly.

Perhaps CMS should just do what it said it set out to do: reduce the documentation burden that they created. Make it a little easier to use the EHR that they mandated, and don’t disguise a budget initiative as a regulation reduction.

Perhaps the lesson of the old traveling medicine shows shouldn’t be lost on CMS. Snake oil doesn’t cure anything. That all the promises don’t make it so. The sound bite of “Patients over Paperwork” doesn’t disguise the money grab, so don’t try to hide a bad motive beneath a good one.

is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns for physicians. Dacey is a AAPC-certified coding instructor and has been active in physician training for more than 25 years. He can be reached at 

Articles

Coding expert Bill Dacey reacts to CMS’s 2019 proposed Medicare Physician Fee Schedule that would collapse office Evaluation and Management code levels-and payment rates.

‘Patients over Paperwork’ or bait and switch?

Q: Do you happen to know what the CPT code would be for when we change the packing in a wound after an incision and drainage (I&D) of an abscess? We do these quite a lot. I usually just bill a level 3, but we use a ton of supplies and it is a time-consuming visit. In addition, we are assessing for wound healing and infection.

A: There really isn't a CPT code for repacking and ongoing wound care. They have codes for wound care with debridement, negative vacuum pressure, etc. but nothing for repacking. And it's a common procedure.

I hope at least you are billing the complicated I&D to cover the initial packing. That 10061 instead of 10060 will get you something extra, but most folks bill the EM for this as you indicate. The EM would include the assessment for infection and coverage with antibiotics.

Be sure to also bill for the supplies, suture or surgical kits if you use them with the HCPCS codes as the supplies aren't bundled.

Q: I’m not sure how to code this. I have never had this happen before: A TCM visit, less than 7 days, for a demented diabetic patient admitted for bilateral pneumonia who now comes in with her daughter, a nurse. She came to the office really out of it, could sit unassisted but did not answer or open her eyes. Her vitals and O2 saturation were OK, but her glucose finger stick was 36. So now we are in urgent care/almost call 911 mode, getting orange juice and sugar, and repeating vitals. She gets more awake, we document that sugar is rising, then she is awake and opens her eyes, and can now answer questions at least yes or no. She is here about an hour. Can I code the TCM and a 99215, or extended visit?

A: That’s a tough one in part because you can't use the prolonged codes with a TCM code because the TCM code has no base time to get 'prolonged.' She is clearly at least high-level MDM, so the 7-day TCM is a good fit. A 99215 by time is 40 minutes, so you'd need a total of 70 minutes to get a 99215/99354 anyway.

You could bill critical care if this is a life-threatening event. Just state that you spent at least 30 minutes providing critical care, which is not place dependent. There is no CCI edit that says you can't bill a TCM with critical care.

Some providers report billing 99214 or 99215 with a TCM-and there is actually no edit that says you can't bill a 99215 or other EM either with 99496-but all the guidance on the TCM codes suggests that it was not intended to be billed with an AM on the same day.

It almost sounds like you didn't do much TCM but more of the needed urgent care. Did you do the required med reconciliation? Remember that the TCM needs to be the first E/M with the patient after the hospitalization. If you were to go with a 99215 instead of the TCM, you'd lose the TCM for that admit.

I'd take the 99496 TCM and be OK with that if you think you documented the TCM in terms of the hospital follow-up, Med reconciliation, and other required elements. The RVU is 3.05. A 99215 is 2.11. You're coming out OK, just not as good as a 99215/99354, which you are 10 minutes short for.

A critical care RVU is 4.5. What you did sounds somewhere between high MDM and critical care. It’s your call if you think it met that definition, e.g., was she at risk of a major organ system failure?

Coding expert Bill Dacey explores coding for ongoing wound care and unexpected, extended care for a diabetic patient.

Coding for repacking wound care and diabetic shock 

I know that the contact for use of Transitional Care Management (TCM) codes needs to be made by a clinical person, but do they have to make the first call / speak to the patient first?

: There are lots of questions about this part of the TCM code services. People seem to get hung up in a lot of details that were certainly never specified in either the CPT manual description of the codes or in the even more detailed original Federal Register description of all that went into coming up with TCM services by Medicare.

There are lots of ways that these “contacts” and encounters unfold, not all of them foreseen by Medicare or other payers. But in the end, it all leads to patients getting the kind of prompt attention and hospital follow-up that the codes were intended to produce more of. And don’t forget the big picture: that hospital re-admission rates go down.

The “interactive contact” does have to be made by “clinical staff,” but it doesn’t describe any of the circumstances as to how that arises. Often, when outreach staff attempts to reach a patient-and gets a recording and leaves a message-when the patient calls back they get the front desk or clerical staff. It’s hard to get them back to the nursing loop. Has the contact been made?

Some providers find out that their patients are discharged from the hospital, text their MAs with instructions to call the patients as soon as possible to answer questions and set up the appointment. That works when the calls are made on time. The point is that there are lots of ways to get there relative to the contact, even to the point of leaving the message.

And remember, although attempts to have this interaction should continue per Medicare guidance, the contact itself is not an absolute requirement to billing the service. You need to document the attempts and/or the contact. The core service is the face-to-face visit furnished within the timeframe required by the code. Stop sweating the details that are not spelled out anywhere and settle on a course that works for most of your patients.

Are there specific diagnosis codes that are required for the advanced care planning (ACP) codes?

: No; per Medicare anyway there are not. The guidance that Medicare puts out on the subject says, “No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit.”

Sounds good and quite reasonable. Then you look at some of the denials for the ACP codes, and they make sense too. Recently, we saw a trigger finger diagnosis linked to the ACP code. It was denied. Like any other service, ACP is subject to medical necessity criteria, and if a diagnosis that would make sense is reported in conjunction with ACP, it will likely be paid.

Once again, watch your CPT and ICD-10 relationship. What story are you telling?

CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Email him your questions at billdacey@msn.com.

Is a phone message sufficient to use the TCM coding series? Plus, guidance on advanced care planning codes.

Establishing ‘contact’ under transitional care management codes            

Q: I’m a hospitalist and have a question about documenting my assessment and plan. For the primary presenting problem, I see the billing modifiers for "worsening," "stable," and "improving." However, I'm not sure where "unstable but not getting worse and not yet getting better" fits in? I mean if the patient will be better by the time they leave, they clearly aren't currently "stable.”

: This sounds like you are describing some menu options your EHR gives you to “characterize” problems in the A/P. This perspective is uniquely yours as the provider creating the note. Coders don’t see this from your perspective as the notes are reviewed after they are done. So it sounds like they've only given you three “flavors” to pick from... which is not nearly enough.

The CPT book and various other coding resources use lots of words to describe “moderate” level decision-making. Worsening, exacerbated, progressing, unstable, uncontrolled, poorly controlled, inadequate control, minor complication, inadequate response to treatment, side effects of treatment, increased risk of functional impairment, uncertain prognosis....

They all seem to reflect “activity” or “not stable.” So to communicate the patient’s actual status, somewhere in there is your language. Your soundbite.

If your list of variable “descriptors” is editable, give yourself every version of the language above and add your own. It might not hurt to add some that cover a few situations, like “Patients overall condition improved but remains guarded due to multi-system disease.”

Be more specific and describe potential disease interactions. Sit down and think of all the common ones, and their over impact on M/M. If you make a good list, pick from it as needed. And hopefully you can always add more.

I saw a new patient that was recently discharged from rehab. Can I bill for a Transitional Care Management code? Or not because I was not the patient

: The TCM codes are about transitioning back into the community and dealing with problems of at least moderate level complexity. They are not limited to a particular provider type, although they were designed with primary care in mind. You do not have to be the “owner” of the patient, or the problems, for you to assess them.

Two of the requirements that Medicare outlines are:

• The healthcare professional accepts care of the beneficiary post-discharge from the facility setting without a gap; and

• The healthcare professional takes responsibility for the beneficiary’s care.

If you meet these criteria, as well as the other TCM requirements, you are good to go. Do remember though that only one provider can bill the TCM service per hospitalization.

My office manager is telling me that I shouldn’t list the patient’s major problems when I’m treating only one of the patient’s chronic problems. I thought the new “quality” approach required that I report all the diagnoses that the patient had in order to illustrate their “complexity.”

 You are both right; sometimes. It’s true that the HCC risk-adjustment oriented reimbursement systems need to see all the problems that the patient has to get a proper measure of risk. But you only report those that you evaluate in any one encounter, or those that impact the ones you are managing.

What your office manager is likely saying is that for encounter-level reporting purposes, you have to stick to the problems at hand. From the ICD-10 guidelines:

"Code the Diagnosis, Condition, Problem or Other Reason Chiefly Responsible for the Services Provided

Also Code Any Coexisting Conditions Relevant to the Encounter (i.e., Conditions that Require or Affect Patient Care, Treatment or Management)."

This month's coding questions tackle the issue of problem “status,” TCM codes, and "quality" coding.

Communicating problem status in the assessment and plan

Q: To bill a 99397 along with a Medicare Annual Wellness Visit, do I have to document how much time I spent with a patient on this topic?

A:  No, neither of these codes has any time component to them whatsoever - so that will not be of any use. A larger answer to your question is that we don’t usually see a 99397 and an AWV. Medicare does discourage this and says there is too much ‘crossover’ between these two preventive services.

We usually see a 99213 or 99214 with a G0438 or G0439 to represent the problem management outside the AWV. If you bill G0438/G0439 and a 99397, recognize that Medicare does not cover the 99397. Some Medicare secondary payers will, but you’d better have pretty good knowledge of the patient’s payer type or else you are consigning them to a pretty big bill, likely a lot too for the screening labs that could go with it.

All that said, if you bill both of these codes, you’d better label each section precisely and say what you are doing in the chief complaint (i.e. Here for Medicare Annual Wellness visit and Annual Physical Exam/ Health Maintenance). Be sure you have all the AWV elements under that heading, and do a decent life-cycle commentary, review of systems, patient family and/or social history, and comprehensive exam. It needs to look like two very distinct things.

Q:  If we do a pap/pelvic/breast exam during a physical exam (99395, 99396, etc.) should I be billing separately for that? On my current billing sheet, there is a G0101 for Medicare patients and a Q0091 for pap.  Should I be circling the second one for a non Medicare patients (since we don’t typically do pap tests on Medicare patients unless there is a problem)?

Are there any RVUs attached to these G-codes? If I do the pap on a separate day from the physical exam would I code something differently?



A:  The commercial Health Maintenance visit codes (99381-99397) include a pelvic and breast exam. It is assuredly part of the 'age and gender appropriate' physical exam.

Medicare, which doesn't pay for the above codes, recognizes the G0101, Q0091 as their AWV visits. The G0439, etc. does not include a physical - and so these female wellness ‘carve-outs’ are payable. But as you say - you won't do many of these on these patients, unless there is an issue - and that’s not pure screening.

Where we cannot give certain infallible guidance is on the variety of Medicare Advantage plans - we have to say only that if they pay 99381-99397 they probably don't want a G0101 with it. But there can easily be exceptions to that.

And yes, the G0101 Pelvic/Breast Exam has .45 RVUs, and the Q0091 - obtaining pap has .37. The pap on a day different than the exam can be a long conversation. As a primary-care, you might get these in several ways:

1. In a follow-up to an annual where for some reason the pap couldn’t be completed the first time – in which case the payer could rightly expect that you were just ‘finishing’ the annual that you already billed them for.
2. If you are female provider, you end up doing a pelvic separately because the male provider that did the annual directs the pelvic portion of a female exam to you as a practice protocol. Again, the payer may not recognize that there was medical necessity for another visit, beyond the first one, where they had already paid for a complete annual.
This could be made even more complex if the other provider is in another group. If you have a diagnosis, then again these are not purely screening and should be adjudicated based on the payers billing policies.
What you do not want to do is to bill pelvics and/or paps apart from an annual, which are really integral to the overall screening exam, and ‘find’ a diagnosis to get these paid.

Coding expert explains why we don't typically see a 99397 and an AWV, and why Medicare discourages this from happening.

Coding Medicare Annual Wellness Visits Along with a 99397 

Q:   We saw a patient today and it appears that the vitals we entered were not saved to the system and we are unable to recall what the actual vitals were, I know that vitals are important to being able to bill for a visit, is there a way that we are able to document that the vitals are lost and if so, are we still able to bill for the visit?

A:  Most E&M visits beyond a 99211 include the ‘constitutional’ or ‘general’ system on exam, but they don’t have to.  Primary-care physicians document principally under the 1995 documentation guidelines - which are at the organ system level. So comments such as 'ill appearing' or 'well-appearing NAD' count as constitutional - you don't actually need vitals.

It is likely that your docs typically document well-enough that one minor miss like this wouldn't impact coding. Just to be thorough, and from a risk management perspective, the MD may wish to add an addendum that for some reason vitals were not recorded but that there were no major concerns.

Q:  Are “vital signs” required to bill a 99211 for in-office [Internationalized Normalized Ratio] check? 

 CPT code 99211 is the only code in the office or other outpatient setting category with no specific documentation elements for the extent of history, examination, and medical decision-making required. We really just need to see an indication that the MD was involved in the decision-making typically associated with review of meaningful information obtained by nursing or other staff.
Anything to the contrary probably stems from the old 'nurse visit' mythology; that it's about what the nurse does, which usually includes vitals. It’s not about what the nurse does – it’s the MD review of data and any subsequent management that you are getting for.

Q: I was wondering if you could give me any guidance about using time for coding when the time is 20 minutes, since that is exactly between the 15 minute/99213 and the 25 minute 99214?  I am running into this quite often because they have changed most of my appointments to 20 minutes and there are times where the patient is fairly stable with [for example] two problems and doesn’t require a medication change, so I would normally put 99213. However, there may be something requiring discussion that extends the appointment to 20 minutes. 

Example: this morning I had a female patient who is getting ready to start having a family in upcoming months so we discussed medications vs no medications in pregnancy, how we could taper her, etc.  It was 20 minutes on the dot.

The bad news is that Medicare has pretty clearly said that the 'midpoint' rule - meaning more than halfway between two time listed as below qualifies you for the higher code - does not apply to the E&M codes.
So if your practice is using the more conservative Medicare guidance for all patients, then the mid-point isn’t much use for E&M codes. The AMA and the CPT manual endorse this - Medicare specifically doesn't. So at least for Medicare/Medicaid and TRICARE - if you are between two 'typical' times you have to use the lower. For commercial payers you could go with the midpoint (i.e. 21 minutes is enough for a 99214). But that said, 20 minutes on the dot will still fall to a 99213 every time if you are coding by time.

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In this month's coding column, our expert answers whether or not you need to include vitals when coding a patient encounter.