I. Background - RBRVS System
The resource based relative value scale (RBRVS) was instituted in 1992 after studies had been conducted to determine the time and intensity of physician work involved in providing various services. At that time, no data had been collected on actual practice and malpractice expenses, so their relative value units (RVUs) were later developed according to a formula specified by Congress. This formula took into account historic payment levels under the old usual and customary system. In 1994 a law was passed by Congress which required the Health Care Finance Administration (HCFA) to develop a methodology and collect data for calculating resource-based RVUs for the practice expense component of physician services. The proposal made by HCFA in 1997 was based on a flawed methodology which favored redistribution of values to out-patient services from in-patient services. This would have resulted in an increase for office-based practices of approximately 12 percent with a reduction for procedural-based practices ranging from 10 to 40 percent.1 A great deal of opposition was mounted against this proposal, and HCFA released a revised proposal on June 5, 1998, which will reduce allowed charges for most major cardiac and thoracic procedures by approximately 14 percent, phased in over a four year period beginning January 1, 1999. The estimated average reduction is 14 percent for cardiac surgery and 13 percent for thoracic surgery. The revised proposal is based on data in the socioeconomic survey of the American Medical Association, which is based on phone interviews with a random sample of physicians in private practice. Top/down is the new methodology adopted by HCFA for practice expenses.2 The present methodology is still problematic, however, because the database for small specialties such as cardiothoracic surgery is limited. The AMA survey also includes only physicians in private practice and excludes those in academic practices where expenses tend to be higher. Work values are likely to be inaccurate since previous estimates have undervalued the pre and post surgery time of increasingly more complex surgical procedures.
Current issues dealing with evaluation and management (E&M) coding date back to the institution of the RBRVS system in 1992. At that time the values that were assigned for a specific service were the same throughout the country, and differences in payment amounts were due only to geographic variations and costs. This system was thought to be inaccurate, however, because visit codes for various levels of services were interpreted differently by physicians in different parts of the country. The CPT advisory committee reviewed E&M codes and in 1992 published new current procedural terminology (CPT) codes for E&M services. The new codes were confusing to physicians, however, and the result was that the government mandated that HCFA adopt documentation guidelines for the E&M codes.3 Documentation guidelines were developed in conjunction with the AMA CPT editorial panel and were first published in 1995. These guidelines specified the information which should be included in a patient's clinical record for each level of service of the E&M codes. Although these 1995 guidelines were HCFA policy, physicians have not been required to follow the guidelines, precisely and until last December, HCFA did not enforce the requirements rigorously. The guidelines were not well received by physicians who sometimes found them to be contradictory. Several years have now been spent refining the coding instructions, and in May, 1997, the AMA and HCFA released new documentation guidelines for E&M services. The guidelines did not differ dramatically from those released in 1994, but one significant change is the establishment of content and documentation requirements for examinations of 10 single organ systems. These include the following: cardiovascular; ear, nose, mouth and throat; eyes; genitourinary; hematologic/lymphatic immunologic; musculoskeletal; neurological; psychiatric; respiratory; and skin. The documentation requirements for multisystem examinations have been changed and the content of these examinations has been defined very specifically. The major concern about the new guidelines is that HCFA has stated that these are not simply directives but are mandatory guidelines. HCFA has now instructed Medicare carriers to audit physician's billings before paying claims if they believe such review is needed. This varies greatly from the directive of the 1995 CPT guidelines. Physicians have expressed a great deal of concern that simple documentation errors could lead to criminal penalties. A number of medical societies have responded to the new guidelines and have requested a delay in implementation. The guidelines were put on hold following a meeting of major specialty societies in April, 1998, and the implementation schedule is now unclear. Nevertheless HCFA and the AMA have stated that physicians must document E/M services according to one of the sets of guidelines. HCFA is currently auditing E/M claims and checking to be sure that either the 1995 or 1997 guidelines are followed. At the present time, providers may choose to follow either documentation guidelines published in 1995 or those published in 1997.
II. Fraud and Abuse
Following the Balanced Budget Act of 1997, the government has taken a strong interest in potential Medicare fraud and abuse. Providers convicted of three healthcare-related crimes are permanently excluded from the Medicare system and triple damages may be sought if they are found to be guilty. Cardiothoracic surgeons have been audited along with other providers through random claims audits of evaluation and management services. Of particular concern are consultations billed to Medicare for angioplasty standby without careful documentation of required coding criteria. Assistant at surgery services are also somewhat vulnerable with these audits. Surgical assistants will not be paid for procedures where assistants are used less than 5 percent of the time. Surgical assistants are only paid in these cases when state law requires their presence by overriding the Medicare rules. Surgical assistants must be present and scrubbed for the key portion of the operation, and they must actively participate in the surgery.
III. General Coding Concepts
A good understanding of the ICD-9-CM and CPT coding process is fundamental to successful coding. The top billing errors recorded by Medicare carriers are the following :
Medicare uses screens for monitoring the coding level of E/M codes. HCFA has also released national statistics for evaluation and management services processed during the second half of 1995. These data should be reviewed in order to understand one's billing practices compared to those of peers. Documentation is absolutely essential and payers will not consider a procedure fulfilled if it is not documented. "Big money losers" include unclean claims, omission of modifiers, failure to track reimbursement, failure to use a full range of E/M codes, and improper use of consultation codes. It should be noted that billing only low-level codes will not only hurt reimbursement but may also trigger an audit since those targeted for audit will include all physicians billing outside of a normal profile. Consistent unbundling can be considered fraud and must be carefully avoided. The physician is ultimately responsible for all actions of his or her office and will be held responsible in an audit.1. Incorrect or missing modifiers
2. Incorrect or missing diagnosis and/or indicators
3. Incorrect or missing procedure codes
4. Not including referring/ordering physician's name and UPIN
5. Missing or incorrect place of service
6. Failure to include the provider's name and number
7. Quantity billed amounts are incorrect or missing
8. Not including extra information that is required
9. Date of service incorrect or missing
IV. Evaluation and Management Codes
Thoracic surgeons generally see patients with a high-level of complexity. These patients often have significant comorbidities necessitating complicated management strategies. Most of our procedures are performed under a global surgical bundle although other evaluation and management codes such as the emergency codes or critical care codes may be used in some cases. With the significant fee reductions that cardiothoracic surgeons have experienced in the last few years, an understanding of E&M coding is mandatory at this point in time. Improper coding may result in charges of fraud and proper documentation is essential. From the perspective of any payer, if it is not documented, it wasn't performed. During an audit, Medicare representatives may review the charges from the previous three months and determine that you have over-coded or possibly charged for services not performed. They may then decide that you performed at that same level for up to seven years and charge you in fines and penalties for the entire period.4
E&M codes are divided into categories with different levels of service based on components and elements. History, physical examination and medical decision making are the key components in selecting a level of service. In every visit or consult, you must document that you met the requirements of all three key components. The history is made up of three elements including history of present illness, review of systems, and past medical, family and social history. Medical decision making is made up of the elements: number of diagnoses, complexity of data and risk. The elements of physical examination are described by the various portions of the physical examination. Other components are considered secondary or contributory and must be well documented. If counseling or coordination of care entails more than 50 percent of any face-to-face patient encounter, time becomes the key factor and overrides the requirements to satisfy the three components noted above.
Documenting Medical Decision Making
Decision making is the carefully documented diagnosis, impression and assessment for each encounter. ICD-9-CM diagnosis codes should be included. One must also document all tests and their assessments as well as supplemental patient history. Any factors that could increase the complexity of this decision making should be documented, including any risks associated with the proposed treatment. Only known diagnoses should be used for ICD-9-CM diagnosis codes.
Time may be used as a primary component in billing. When time is the determining factor, it becomes the key component and overrides requirements for other components. This must be carefully documented and would include counseling and/or coordination of care which entails more than 50 percent of the physician's time with the patient. It is also the key factor in critical care codes. Outpatient time is considered the face-to-face time spent with the patient. This would not include time spent on activities such as record review or dictation. In-patient time is time spent "on the floor" and does include record review, review of imaging tests and dictation.
Critical Care Codes
Critical care codes (99291-99292) are for use in cases where a patient who is critically ill requires the constant care of a physician. This is usually care given in a critical care area and can only be rendered by one physician at a time. These codes are normally not available to cardiothoracic surgeons under a global fee structure, but may be applied in cases such as failed angioplasty with hypotension and cardiogenic shock. When using these codes, one may not bill for several other codes which are considered bundled. These include: 36000, introduction of needle or intracatheter, vein; 36600, arterial puncture to collect blood; 91055, gastric intubation; 93561, cardiac output by indicator dilution studies; 94656, ventilator care, day one. Duration of critical care may be charged only once per day but need not be continuous.
The following codes may be billed when using critical care codes: 92950, cardiopulmonary resuscitation; 92960, elective cardioversion; and 31500, endotracheal intubation, emergency; 32002, thoracentesis. Defibrillation procedures performed during cardiac arrest cannot be billed separately from critical care services.
Services not Reimbursed
A patient is considered by Medicare to be established if any member of a specialty group has seen that patient within the last three years. This does not apply to physicians in the same group who practice in unrelated specialties. The following codes are not being reimbursed by Medicare:
V. Global Surgery Rules
In Medicare, the global fee includes the day before the procedure and a designated number of days afterwards, either 0, 10, or 90. In dealing with global fees, modifiers represent the only way to be paid for additional services. In cases where there is no followup under the global fee schedule, such as endoscopic esophagoscopy with injecting sclerosis of esophageal varices (code 43204), one may charge for everything one does for the patient following the surgery. Modifiers -54, -55, and -56 are designed to identify situations where postoperative management is provided by someone other than the operating surgeon. The surgeon should utilize these modifiers carefully since use of modifier -54 will reduce the global surgical fee by 8 to 40 percent. Thus, cardiothoracic surgeons who transfer post-operative care to another specialist stand to lose a significant amount of reimbursement. One should also be careful to use modifier -57 to receive reimbursement for a hospital or office visit in which the decision to perform the procedure was made within 24 hours of the procedure.
Critical care services may not be billed during a global fee period in most cases. Exceptions include the global fee period for a seriously injured or burned patient. Cases where the services are not considered to be related to the surgical procedure may be billed separately with modifier -25 for services on the same day as a procedure and modifier -24 for postoperative care. It is important to carefully document that the critical care was unrelated to the surgery. Postoperative periods of 0 to 10 days have been assigned for minor surgical procedures.
It should be understood there are a number of postoperative complications which may not be billed under the global fee structure. Complications which are not billable regardless of whether the patient is treated during the surgical admission, readmitted, or seen in the office include: post-CABG atrial fibrillation, removal of temporary pacing wires, discharge day management, postoperative line changes, and bedside chest tube insertions. Postoperative conditions which are billable if the patient is returned to the OR a special procedure room: treatment of wound infections, chest tube insertion, pleural effusion/thoracentesis, closure of sternum, removal of buried sternal wires, evacuation of leg hematoma, tracheostomy, and bronchoscopy.
VI. Modifiers
The following modifiers should be understood and utilized by cardiothoracic surgeons:
- Prolonged E&M services--Replaced by prolonged services codes (99354-99359) Unusual services -22
- Unrelated E&M service during post-op period -24
- Separate E&M service on day of surgery -25
- Professional component -26
- Bilateral procedure -50
- Multiple procedures -51
- Reduced services -52
- Discontinued procedure -53
- Decision for surgery -57
- Staged or related procedures by the same physician in the post-op period -58
- Surgical team -66
- Repeat procedure by the same physician -76
- Repeat procedure by another physician -77
- Assistant surgeon -80
- Minimum assistant surgeon -81
- Assistant surgeon qualified resident is not available -82
- Multiple modifiers -99
References
1. Anderson R. Newsletter. Soc Thor Surg. June 25, 1998.
2. Opelka F. In their own words. Bulletin of the Am Coil Surg. 1998; 83:35-39.
3. Schneidman DS. New documentation guidelines for E&M services: Their evolution and status. 1998; 83:7-14.
4. The Thoracic and Cardiac Surgery Coding and Reimbursement Source Book. PRS: Denver, 1998.