Coding and Reimbursement Primer
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CARE RESEARCH PREVENTION REHABILITATION TEACHING Coding and Reimbursement Primer 2018 EDITION American Burn Association 311 South Wacker Drive, Suite 4150 Chicago, IL 60606 (312) 642-9260 www.ameriburn.org American Burn Association 311 N. Wacker Dr., Suite 4150 Chicago, IL 60606 (312) 642-9260 Copyright © American Burn Association 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2017, 2018 All Rights Reserved. CPT codes, descriptions and material only are copyright 2000-2017American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Disclaimer: Although the American Burn Association has taken reasonable steps to ensure the accuracy of the information presented in this Primer, this publication should not be construed as providing professional advice or consultation. Readers are encouraged to consult with knowledgeable coding consultants on specific issues affecting them. The American Burn Association assumes no legal liability for the information contained herein. This publication was made possible in part through an unrestricted educational grant from the Integra Foundation. CPT codes, descriptions and material only © 2017 American Medical Association. All Rights Reserved CPT® is a registered trademark of the American Medical Association ABA Coding and Reimbursement Primer – 2018 Edition 3 Burn surgeons are involved in exciting and truly changing times. The advent of tissue engineering, coupled with the expanding role of government in health care, including the Centers for Medicare and Medicaid Services (CMS), third party payers, HMOs, ACO’s, and case management agencies, poses challenges involving not only the physician’s responsibility to the burn patient but also how to address the socioeconomic issues of burn care. Case management and payers in general have introduced their own models of quality assurance. In addition, CMS has developed active programs to detect potential fraud and abuse in the delivery of health care for its Medicare and Medicaid programs. It is evident that the clinical and surgical knowledge and skills of a burn surgeon are not enough to ensure success. It is also necessary to learn to properly code burn diagnoses and to appropriately code medical services and procedures performed on the burn patient. The burn surgeon cannot be content allocating this task to coding personnel. Correct coding is the responsibility of the burn physician. It is dependent upon appropriate documentation and a daily reporting mechanism for the medical and surgical services rendered to the burn patient. To address this challenge, burn surgeons must become familiar with a group of acronyms: ICD-10-CM, ICD-10-PCS, CPT, E/M, MS-DRGs, RBRVS, HCPCS and others. This manual is designed to address the most important coding and reimbursement issues affecting burn surgeons and to provide relevant information to help avoid liability for fraud or abuse. The content of this coding manual is based on current (as of this publication) CPT and Medicare/CMS coding and reporting guidelines, where applicable. In cases where the two sources diverge significantly (e.g., designation of burn wound excision as global vs. minor surgery), the policy distinction is explained. CPT and Medicare/CMS are generally recognized as setting the national standard for coding and reporting. However, coding and reporting guidelines can and often do vary from community to community and state to state. Any non-Medicare payer may elect to adopt some or all of the national standards or deviate from them in whole or in part. Therefore, this manual does not attempt to address coding and reporting that is unique to a specific geographic region or given payer. Burn surgeons and coding staff are encouraged to utilize the manual as a standard coding reference while following any local payer coding and reporting guidelines that may vary from the national standard. CPT codes, descriptions and material only © 2017 American Medical Association. All Rights Reserved ABA Coding and Reimbursement Primer – 2018 Edition 4 ACKNOWLEDGMENTS The 2018 ABA Coding Primer represents the Association’s continued commitment to providing burn centers and ABA members with pertinent information to enhance documentation and coding for the care of patients treated in burn center hospitals. It would not have been possible without the ongoing contributions of a number of dedicated and knowledgeable individuals: William Hickerson, MD, FACS (Chair of the ABA Coding Committee) and the following staff in the ABA Central Office: Kimberly A. Hoarle, MBA, CAE, Executive Director and Maureen T. Kiley, BA, Senior Program Director. The Association thanks Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, for serving as project consultant and, in that capacity, sharing her dedication, enthusiasm and extensive coding expertise. Special thanks and appreciation are also extended to the Foundation of Integra Lifesciences Corporation for their support of the Primer. CPT codes, descriptions and material only © 2017 American Medical Association. All Rights Reserved ABA Coding and Reimbursement Primer – 2018 Edition 5 Table of Contents Introduction & Purpose of Manual .........................................................3 Acknowledgments .................................................................................4 CODING FOR PHYSICIAN SERVICES Key Concepts ...................................................................................... 11 What is Coding? ..................................................................................... 11 Coding Systems for Physician Claims ..................................................... 11 Procedures, Services and Supplies Furnished by Physicians • Diseases, Conditions Evaluated /Treated by Physician • Coding Systems—Effective Dates of Annual Updates • Recent CPT Changes Affecting Burn Surgery for 2018 Relative Value Update Process (RUC) ...................................................... 16 Claim Forms for Physician Services ........................................................ 16 What Makes a Claim Payable? ................................................................ 17 Defensible Documentation ...................................................................... 17 Establishing Medical Necessity ...............................................................19 Unbundling and Bundling ...................................................................... 20 MUEs—Medically Unlikely Edits (Medicare) ............................................ 22 Global Periods ........................................................................................ 28 Global Surgery Package, CPT Surgical Package • Medicare Global Surgery Package • Medicare Coding Case Studies (1.0 & 2.0) for Single or Multiple Physicians, Same Group, Caring for Same Patient • CPT “Add-on” Codes Modifiers ................................................................................................ 53 Modifier Essentials • Modifiers Most Commonly Used by Burn Surgeons • Surgical Modifiers Frequently Used by Burn Surgeons • Evaluation and Management Modifiers Used Frequently by Burn Surgeons Multiple Surgical Procedures .................................................................. 63 Reduced Payment • What is a Secondary Procedure? • Reduced Payment Not Applicable to Add-on Codes & Modifier 51 Exempt Codes • Ranking Procedures on the Claim Assistant at Surgery: Medicare ............................................................... 66 CPT codes, descriptions and material only © 2017 American Medical Association. All Rights Reserved ABA Coding and Reimbursement Primer – 2018 Edition 6 Fraud and Abuse .................................................................................... 67 Physician Claims for Services Must Be Performed or Provided Directly by the Physician • Two Situations Where the Physician Can Bill for Services Performed by a Different Clinician • Underlying Regulations and Guidelines • Summary of Key Points • Medicare Fraud, Waste & Abuse Training Required for Physicians Evaluation & Management (E/M) Services ............................................ 70 Documentation: Key Concepts ................................................................ 70 CPT & Medicare Definitions of New & Established Patient • Categories of E/M Codes • Types of Problem-oriented E/M Codes • Selecting the Correct E/M Code for Level of Service—Determined by Documentation • CMS Requirements/Selecting E/M Codes • CPT & CMS Documentation Requirements • Documentation for Separate E/M & Minor Surgical Procedure, Same Date of Service Basic E/M Reporting Guidelines ............................................................. 73 1 E/M per day • Unbundling and Bundling E/M Services • E/M Services and the Surgical Package Shared E/M Services: Physician and Non-Physician Practitioner ............ 79 Unique Medicare-Only Concept •Medicare Payment Differential • Place of Service Requirements • Physician & NPP in Same Employer Group • Physician & NPP with Different Employers Typical Burn E/M Services ..................................................................... 89 Emergency Department Service (99281–99285) • Consultations (99241–99255, 99251-99255) • Admit H&P Only (99221–99223) • Critical Care (Hourly) (99291–99292) • Inpatient Pediatric Critical Care (99271-99276) • Inpatient Neonatal Critical Care (99468-99469) • Inpatient Daily Visits (99231–99233)