You could find your doctor’s SNF visits under the microscope soon. E/M code use has been drawing suspicion for quite some time. Now NGS Medicare is joining the Centers for Medicare and Medicaid Services (CMS), in going over subsequent nursing facility visit codes 99309-99310 with a fine-toothed comb.

NGS, a Part B payer, announced on May 7 that it had recently reviewed claims for these codes and found that its providers in Connecticut, New York, and Massachusetts appeared to collect for a higher percentage of these visits than expected.

Based on the outcome of the review, NGS said that it “will be conducting service-specific prepayment reviews of subsequent nursing facility visit codes 99309-99310.”

Know these quick facts before you report these nursing facility care codes in the future:

1. Check documentation for comprehensive interval history, comprehensive exam, and/or high-complexity medical decision-making before reporting 99310. CPT® requires documentation of at least two of these criteria before you can bill 99310.

For 99309, you’ll need to document two of these three requirements: A detailed interval history, detailed exam, and moderate medical decision making.

If your doctor visits a large number of nursing home patients on the same date (which is common), he may not be documenting enough for each patient to meet these high-level codes. Make sure he takes the time after each patient to thoroughly document the record to support the codes he plans to report.

2. If you’re coding based on time, be sure to document the pertinent details. Ever since 2008, CPT® has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter. For 99309, the “typical time” cited by CPT® is 25 minutes, while you’ll need to spend 35 minutes to justify reporting 99310.

NGS’s review will be used to identify common billing errors, develop educational efforts and prevent improper payments. If you submit the codes in question, NGS will send you an ADS letter requesting documentation. “Medical records that are not received within the designated timeframe will cause the service and/or claim to be denied,” NGS says on its website.

To read more about the review, visit www.ngsmedicare.com.

A recent clarification on critical care services from the Centers for Medicare and Medicaid Services (CMS) should come as a major relief to your physicians as well a boost to reimbursement.

Scenario: Your physician performs CPR for a non-responsive patient in the observation care unit of the hospital, where he attends to the patient for 30 minutes, and the patient is later moved to the ICU, where your physician sees her for another 75 minutes evaluating her need for a mechanical ventilator, feeding tube and accompanying sedation while she stabilizes. Your physician bills for 70 minutes of critical care services, right? Wrong.

Myth: Although many physicians believe they can only report critical care services for patients who are in the hospital’s intensive care or critical care unit, that longstanding belief is a myth.

Reality: CMS defines critical care as “a physician’s direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” Therefore, if your physician performs critical care services for a patient in shock, renal failure, circulatory failure, or other life-threatening conditions, you should be able to report critical care services.

In black and white: CMS addresses the confusion in MLN Matters article MM5993, noting, “While critical care is usually given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit or the emergency department, payment may also be made for critical care services that you provide in any location as long as this care meets the critical care definition.”

In our example above, the physician providing the critical care services would report one unit of 99291 (Evaluation and management of the critically ill or critically injured patient, first 30 to 74 minutes) and one unit of 99292 (…each additional 30 minutes…) to cover his 105 minutes with the patient.

Remember that your physician must be treating vital organ failure and preventing further deterioration during his critical care services to be considered medically necessary. “Therefore, delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service,” CMS says.

To count your physician’s critical care time, add the time he spent giving full attention to the critically ill patient and not any time providing care to other patients.

Remember the Other Side of the Coin

Just as you can report critical care services for any location if the patient meets the criteria, the opposite is true as well. If a patient is in the critical care unit and your physician treats her for a non-life-threatening condition, you cannot report critical care services. For instance, if a patient is in kidney and lung distress due to Goodpasture’s Syndrome (446.21) and your dermatologist treats the patient for an accompanying topical rash in the critical care unit, the dermatologist cannot report the critical care codes.

Resource: To read CMS’s MLN Matters article on this topic, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5993.pdf.

Answer: Your physician can get paid for E/M services and minor surgeries he performs in a teaching setting, as long as you send in the proper documentation along with the claim. When reporting your physician’s work in a teaching setting, file documentation according to the rules laid out in Section 15016 of the Medicare Carriers Manual. If the resident performs an E/M service, the teaching physician has to do one of two things:

1. Personally participated in key or critical aspects of the patient’s evaluation. So let’s say the resident performs a level 4 E/M service on a patient. In order to report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) for the encounter under teaching physician rules, the physician should write a note with case specific detail showing that he personally performed the key /critical portion of the patient’s evaluation

2. Be present during key portions of the exam. If he is present during the resident’s E/M evaluation, the teaching physician does not need to repeat the whole process, — but the teaching physician does need to document his physical presence during the key/critical aspects of the evaluation to support the claim.

So if the resident performs a level 4 E/M service with the teaching physician present, you should report 99284. On the claim, include documentation that shows the teaching physician was present for the history, examination and MDM portions of the encounter.

Myth: You should work twice as hard on the title of your physician’s medical record than you should on the note itself, because the title is enough to justify the codes you report.

Reality: The physician must document the services he performs in the body of the record or an auditor would assume that he didn’t perform the procedures.

For instance: Suppose the subject of the physician’s note is “Alan Johnson’s corticosteroid injection,” but then he only dictates details about the diagnosis and E/M service (not an injection) in the body of his report.

Solution: You can report the E/M service but not the injection.

Explanation: Most coders and auditors do not use the title in their review of the documentation. If it is not indicated in the body of the note, it is presumed that it was something that wound up not happening. The body of the note should match the title as closely as possible to all the things done during the service session.

The documentation should include the location of the injection site, whether it was unilateral or bilateral, and the exact substance being injected. The report should name the medication and the quantity used so you’ll be able to select the correct number of units of the applicable HCPCS code. In addition, you’ll want to document any anesthetics used as well as whether the injection was made under guidance.

This advice goes both ways—just as you should document the entire procedure that the physician performs, you should also ensure that complete documentation exists for the E/M service so you can get paid for both separately identifiable procedures.

Michigan Subscriber

Answer: The code 93924 (Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, [i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery] complete bilateral study) applies to noninvasive physiologic studies done in the lower limb arteries at rest and following stress test on treadmill. Therefore, the code includes the charge for treadmill stress testing.

Ideally, a motorized treadmill is used for the performance of these tests. The testing is done at a constant speed and grade, e.g.; 2 mph speed with a grade or incline of 12 percent. Your radiologist may document that the patient has walked on the treadmill for five minutes or until symptoms were reported and the patient was forced to terminate the exercise protocol.

Also: The physician will take and record pressures at timed intervals following performance of the exercise protocol.

Sometimes a patient whose case you’re coding has a pacemaker or automatic implantable cardiac defibrillator (AICD), but that’s not the reason the physician is treating the patient. You still need to include the device when listing diagnoses, but will look for codes in a different section when ICD-10 is implemented in October 2015. You’ll shift from “V” to “Z,” but the codes themselves won’t change much.

Currently, with ICD-9, you have two coding options for the diagnosis:

• V45.01, Cardiac device in situ; cardiac pacemaker
• V45.02, Cardiac device in situ; automatic implantable cardiac defibrillator. 

ICD-9 coding rules: You use V45.01 and V45.02 to indicate the presence of the named devices. If the patient has an AICD with synchronous cardiac pacemaker, you should report V45.02. If the patient has a malfunction or other complication, you should instead code that condition. And if the patient presents for fitting or adjustment, you should use V53.3x (Fitting and adjustment of cardiac device).

ICD-10 changes: You’ll still rely primarily on two codes for your diagnoses in ICD-10:

• Z95.0, Presence of cardiac pacemaker
• Z95.810, Presence of automatic (implantable) cardiac defibrillator.

ICD-10 offers a one-to-one code correspondence to your ICD-9 options. You’ll use the AICD code when the patient has an AICD with synchronous cardiac pacemaker. As with ICD-9, you should use a different code range for complications: T82.- (Complications of cardiac and vascular prosthetic devices, implants and grafts). And for adjustment or management, you’ll turn to Z45.0- (Encounter for adjustment and management of cardiac device).

Documentation: Your providers’ documentation should not need to change for you to choose the appropriate ICD-10 code.

Coder tips: Although these codes have a one-to-one match between ICD-9 and ICD-10, they are not organized the same way. In other words, if you look at a list of ICD-9 codes, V45.01 is followed immediately by V45.02. In ICD-10, there are a handful of codes between Z95.0 and Z95.810, the latter of which requires two more digits than Z95.0. If you use the index and then verify your code in the tabular list, these structural changes shouldn’t put a hitch in your coding.

Remember: CMS has finalized the ICD-10 compliance date of Oct. 1, 2015. When ICD-10 is implemented, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.

Answer: Whether you report each small breach as they occur or report them all at once at the end of the year, this should not make much of a difference in terms of triggering an audit, answers Jim Sheldon-Dean, founder and director of compliance services for Lewis Creek Systems, LLC in Charlotte, VT.

For small breaches, you only need to report them to the U.S. Department of Health & Human Services (HHS) within 60 days of the end of the year, instead of as they happen like for larger breaches, Sheldon-Dean explains. But certainly some people wonder whether reporting small breaches to HHS in a single batch at the end of the year (along with all the other small breaches from providers) is “less noticeable” than sending the breach notifications throughout the year.

Red flag: What HHS is really looking for — and what may trigger an audit — is whether your practice has similar small breaches that could indicate a systemic problem, Sheldon-Dean warns. HHS will “take a look at all the potential issues and then make decisions as to whether they need to do any kind of compliance investigation.”

New guidance from the Department of Health and Human Services (HHS) may help to answer your toughest mental health information-related questions under the HIPAA Privacy Rule. But if your state’s laws are more stringent, following the guidance will do more harm than good.

On Feb. 20, HHS released new guidance on the HIPAA Privacy Rule and sharing mental health-related information, which is now available at www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html.

Overview: “The new guidance is generally consistent with HHS’s previous guidance concerning communication with patients and families,” attorneys stated in a recent vonBriesen & Roper Health Law Blog posting. Except for psychotherapy notes, the Privacy Rule gives the same protection to all PHI, including mental health records.

Learn the Answers to Your Burning Questions

In the guidance, HHS addresses some of the frequently asked questions (FAQs) regarding the Privacy Rule’s stance on when you can share the PHI of a patient being treated for a mental health condition. For instance, when does HIPAA permit healthcare providers to:

• Communicate with a patient’s family members, friends, or others involved in the patient’s care?
• Communicate with family members when the patient is an adult?
• Communicate with the parent of a patient who is a minor?
• Consider the patient’s capacity to agree or object to the sharing his information?
• Involve a patient’s family members, friends, or others in dealing with patient failures to adhere to medication or other therapy?
• Listen to family members about their loved ones receiving mental health treatment?
• Communicate with family members, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others?
• Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold?

Tread Carefully: Don’t Let Guidance Overrule Your State’s Laws

Although these answers to FAQs are certainly helpful in understanding your duties under the HIPAA Privacy Rule regarding mental health information, you’ll need to keep a close eye on your state’s laws.

Experts strongly encourage you to review your applicable state privacy laws before relying on the HHS guidance. “In many cases, state health information laws are often more stringent, and therefore, may preempt federal regulations,” warned a Feb. 28 HIPAA Alert blog analysis by the law firm Nixon Peabody LLP.

Also: “Keep in mind that the latest HHS guidance does not affect obligations that may arise under stricter state or federal statutes and regulations governing behavioral health (including mental health and substance abuse) records or information,” according to vonBriesen & Roper.

Example: The stricter requirements of federal rules governing the release of substance abuse information and similar state laws still apply and may not allow the disclosures that HHS describes in this latest guidance, vonBriesen & Roper pointed out.

Watch for Changes in Your State Laws, Too

And state laws can vary widely, ranging from very strict to none at all, Nixon Peabody noted. Approximately 46 states and the District of Columbia have confidentiality statutes for mental health treatment records. State laws are also frequently changing.

For instance, providers in Washington State are facing compliance with new statutes regulating mental health record disclosures, which will take effect on July 1, according to attorney Elana Zana with Seattle-based Ogden Murphy Wallace, PLLC.

Lesson learned: You must be mindful of federal and state protections for all health information, particularly sensitive mental health information, Nixon Peabody urged. Make sure that you comply with state-specific requirements before implementing use and disclosure policies related to mental health treatment records.

How to Decide Which Law to Follow

If your state law is different from HIPAA regarding mental health PHI, you need to figure out which law to follow. According to a February 2014 whitepaper by Bruce Borkosky, Psy.D., for MalvernGroup Incorporated, you should use the following decision-making process:

1. If you can find a way to comply with both the state law and HIPAA, then do so.
2. If your state laws are silent on the matter, then follow HIPAA.
3. If the state law gives the patient greater rights or greater information, then follow state law.
4. If the state law is in conflict with or contrary to HIPAA, then you have a dilemma and you may need to seek legal advice.

Answer: A split-night service can sometimes apply when a patient undergoes a sleep study. Frequently performing separate diagnostic and titration services on consecutive nights is unusual, although there are situations in which it may be necessary.

For example, if a provider begins a diagnostic polysomnogram at 9 p.m. and can make a diagnosis of sleep apnea early on, the provider may then begin the titration at midnight or later and complete a split-night service. In this scenario, a provider should submit a single split-night claim. Although the entire care includes both a full-night diagnostic service on the date the procedure began and a full-night titration service on the date service ended, you still report only one code.

CPT® does not include a separate code for a split-night study. You should report 95811 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) for either a split-night study or a PAP titration study. Billing the two portions separately would be the same as billing two procedures when the physician only performed one.

The MUE list includes specific CPT® or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although the edits themselves became public in October 2008.

Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.

Anatomical example: The MUEs edit out and deny an erroneously coded claim for a hysterectomy (for example, 58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) for a male patient.

Unit of service example: The edits also limit the claims for codes such as 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn) to a single unit per calendar day. This makes sense because 99462 is a “per day” code.