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Coding questions? We've got the answers
New AWV Requirements
Q: Is there a change to the requirements for the Annual Wellness Visit (AWV) for Medicare in 2012?
A: Yes. You now need a whole new form called an HRA (Health Risk Assessment). I doubt that it can be included in the form you've likely already developed for your physicians to fill out because Medicare says it will take the patient 20 minutes to fill out. But you'll need to reference it, scan it, and it is supposed to direct elements of the patient's personal plan of care.
Q: Does the new immunization administration's requirement for chart note documentation specify that each immunization must have a counseling note in the chart? Is it possible to have a "blanket" counseling statement that states: "Counseling was provided for the immunizations and components as listed above"? We have received feedback that the chart notes are really long now because the counseling statement "attaches" to each immunization.
A: I know of no requirement that the counseling be specified per immunization. I think that a "group" statement would suffice as long as it covers the immunizations provided. And remember, some subjective information is desired, not all "cloned" statements that attach are sufficient.
Carrier Coding Differences
Q: We are under Palmetto as our Medicare Part B carrier. I recently saw something published comparing the criteria different carriers use for the level of E&M coding. Our current carrier did not seem to include "more than three chronic problems," for example, as criteria for Level 4. Are there big differences in requirements for a 99214 with this carrier compared to other carriers?
A: The carrier would have to have substantially changed the rules not to recognize that aspect of 99214s - it is a mainstay. The table of risk that has been part of the CMS Documentation Guidelines since 1994 actually states "two or more…" I can't imagine that a major carrier would stray so far from the standard document.
Q: We are wondering if the services of our nurse practitioner can be considered an extension of our care plan for Medicare patients, and if so, can we bill these visits incident-to? We have a sick clinic for minor acute problems and many of these patients are seen by a nurse practitioner. The physicians are in the office and available to participate in the evaluation or treatment plans as needed. If we have an office protocol to manage these acute illnesses in our patients who are under ongoing care and the nurse practitioner follows that protocol, is it considered continuing our established plan of care?
A: Wow - excellent question. I was getting ready to say no way on the new problems; it is clear in the regulations that new problems cannot be billed incident-to. But your take on the protocols as an "'established plan of care" is novel. I'm quite sure that that is not what Medicare meant, but you could make the case that this is both practical and a viable interpretation of the regulations. I would ask a healthcare lawyer though, because this hinges on legal advice.
The HHS Office of Inspector General's (OIG) Work Plan for 2012 takes on incident-to with a new angle: "We also found that unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality."
Q: There has been something published by CMS recently about "cloned" notes. I know you have previously mentioned this as a concern. Whether with EHR or transcription, I think most of us tend to use the same verbiage over and over; in part to be sure we don't omit important information. It was my understanding that "cloning" is more of a problem when the review of systems (ROS) or physical exam are identical in note after note and out of proportion to the presenting problem, such as a full physical for a sore throat. Is this correct?
A: You are correct in your observations. EHRs do make things look repetitive, and there are aspects of ROS and exam that are repetitive across patients, to say the least. So there will be similarities and identical notes from visit to visit and between patients. That's why it is so important to personalize the History of Present Illness (HPI) and A/P areas to make today's concerns and management apparent. You do need to keep exams and ROS in proportion to the event. So, use templates, but use them judiciously and be sure to include subjective information each time - don't let the template "become" the note.
Q: Can hospitalists bill for H&Ps for psychiatric unit admissions?
A: There are some different circumstances that affect the answer, but in general, there is no reason a hospitalist can't admit a patient to a psychiatric unit. Most hospitals require patients to be medically cleared prior to an admission to a psychiatric unit, and often this is done in the emergency room. You can bill the consult codes if you are asked to clear the patient, then the psychiatrist can bill the admit. Generally, the admitting service is the service that provides the majority of the care. But there really are few rules about which specialties can do what in terms of the CPT manual.
Q: What does the change in the language for the prolonged services codes mean in CPT 2012?
A: Good question, because this should open the door for more use of this code, although Medicare has made it clear it won't be paying for these in the observation setting. The main change is that the word physician had been deleted from the code description, meaning that the service can be provided by ancillary staff - presumably under physician general supervision in the office or other outpatient setting. The face-to-face requirement has been removed from the inpatient version and observation has been added to the description. The overall impact of these changes makes the code far more accessible.
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 firstname.lastname@example.org or email@example.com.
This article originally appeared in the February 2012 issue of Physicians Practice.