Annual Wellness Visits; RVU Reductions; Physician Scribes

April 28, 2012
Bill Dacey

Medical coding guidance on Medicare Annual Wellness Visits; RVU reductions; physician scribes; student documentation; and more.

Annual Wellness Visits

Q: I've just been informed by AARP/Secure Horizons/PacifiCare (a Medicare replacement plan) that for a routine physical, I can no longer bill with CPT code 99396-99397. Instead, I am to bill according to Medicare guidelines. Does anyone know the code(s) that I can use to bill for yearly routine physical exam? Does this code(s) apply to all of the Medicare replacement plans?

A: Although I can't say for certain, the Medicare replacement plan is likely directing you to use the new Annual Wellness Visit codes G0438 and G0439. The use of these codes is pretty clearly outlined in the Medicare transmittal R2159CP. What I don't know is what a given Medicare replacement or advantage plan is doing with these directions. They can depart from standard coverage but most that I know of generally follow the guidelines. I would ask the plan if it recognizes the codes above, and ask them to show you the written policy or coverage determination.

RVU Reductions

Q: I have a question regarding work RVUs and multiple procedure reduction with modifier 51. What happens to my work RVUs when I have performed a Mohs excision followed by a closure? Is my work RVU automatically reduced?

A: The paragraph in CPT directly preceding the Mohs codes indicates that repairs, flaps, and grafts should be coded separately. The repair codes are also not listed in CCI as component elements of the Mohs codes, so those codes should not be included. However, as the repair will constitute a multiple procedure, and as it is in the exact same incision/excision site as the first procedure, it will be subject to the multiple procedure guidelines and therefore, it will be reduced by 50 percent. So yes, report modifier 51 on the repair (unless the repair RVU exceeded the excision RVU), and yes, you will see an RVU reduction.

Physician Scribes

Q: I hear of a lot of providers moving toward the use of scribes and I want to know what the rules are regarding nonphysicians acting as scribes for physicians. What exactly does a scribe need to write in the note and what does the physician need to write?

A: If a nurse or nonphysician provider (PA, NP, or CNS) acts as a scribe for a physician, the scribe writing the note (or history or discharge summary, or any entry in the record) should note, "written by xxx, acting as scribe for Dr. Y." Dr. Y should co-sign the note, indicating that it accurately reflects work and decisions made by him.

The scribe should function as a "living recorder," recording the actions and words of the physician in real time. Any other way this is done may be deemed inappropriate and result in a denial if reviewed.

It is inappropriate for an employee of a physician to make rounds and make entries in the record, and then for the physician to make rounds at a later time and note, "agree with above," unless the employee is a licensed, certified provider (PA, NP, or CNS) billing Medicare for services under her own name and number. There is no incident-to billing in the hospital setting (inpatient or outpatient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity.

Student Documentation

Q: I'm looking for an opinion regarding how we have our medical students document in patient charts. We know that students can document PMH, FH, SH, and ROS for billing, but not HPI or PE. So we do a kind of "work-around." We have our students document the encounter, then sign as scribe. We then correct and abridge the note to whatever extent necessary. At the bottom of the note, I write something like, "Student Smith acted as scribe for this encounter. I personally performed the history and examination, annotated the above documentation to reflect my findings and assessment, and the plan is based on my assessment and is accurate and complete."

A: This does not strike me as a safe practice at all. The above excerpt says the student is a scribe, however, it references the work the student did. It's a "work-around" as you say, but it works around the rules.

The rules were recently updated in the Medicare teaching guidelines. They state: "Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E&M service and are not separately billable). You, the student, may document services in the medical record; however, the teaching physician may only refer to your documentation of an E&M service that is related to the ROS and/or PFSH. The teaching physician may not refer to your documentation of physical examination findings or medical decision making in his or her personal note. If you document E&M services, the teaching physician must verify and re-document the history of present illness and perform and re-document the physical examination and medical decision making activities of the service."

Note the repeated use of the term "re-document." I think this speaks against your work-around.

Delayed Record Completions

Q: Some of my physicians don't "lock" or "close" their EHR notes until a month, or more, has passed. And, a couple of my physicians still dictate their notes, but can be up to three months late with their dictations. Is there a rule about this?

A: There is no one all-encompassing rule that states when a record needs to be completed. But there are several good reasons why delay is inadvisable. The providers will not remember as many details after time has passed, and so the record will not be as complete as it should be. You shouldn't file claims without the supporting documentation in place. If that isn't incentive enough, CMS says "Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service."

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the May 2012 issue of Physicians Practice.