11/12/2018 1 2019 Reimbursement Update Michael Granovsky MD, CPC, FACEP President, LogixHealth David McKenzie, CAE ACEP Director of Reimbursement ▪ Over half of the 35.4 million annual inpatient admissions in the United States begin in the ED ▪ 5 times as many ED visits are treated and released ▪ ED visits outpaced population growth since 1993 ▪ The number of ED visits increased 14.8 % from 2006 to 2014. The U.S. population grew 6.9% ▪ ED visits by those in the lowest quartile of income rose 23% from 2006-2014 ▪ The rate of mental health/substance abuse-related ED visits increased 44.1 percent from 2006 to 2014 The Safety Net for Society The Healthcare Cost and Utilization Project sponsored by sponsored By The Agency for Healthcare Research and Quality (AHRQ)
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11/12/2018
1
2019 Reimbursement Update
Michael Granovsky MD, CPC, FACEPPresident, LogixHealth
David McKenzie, CAEACEP Director of Reimbursement
▪ Over half of the 35.4 million annual inpatient admissions
in the United States begin in the ED
▪ 5 times as many ED visits are treated and released
▪ ED visits outpaced population growth since 1993
▪ The number of ED visits increased 14.8 % from 2006 to
2014. The U.S. population grew 6.9%
▪ ED visits by those in the lowest quartile of income rose
23% from 2006-2014
▪ The rate of mental health/substance abuse-related ED
visits increased 44.1 percent from 2006 to 2014
The Safety Net for Society
The Healthcare Cost and Utilization Project sponsored by sponsored
By The Agency for Healthcare Research and Quality (AHRQ)
11/12/2018
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National CMS Launches Comparative Billing Report (CBR) Program
Benchmarks: Total Allowed Charges, Avg. Allowed Charges per Visit,
% 99285, Use of Modifier 25 vs State and National
CBR Employed Benchmarks
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▪ Modifier 25- 13% of claims
▪ Average Allowable- $145.75
▪ Percentage of 99285- 56%
MI Specific Benchmarks
Claims with Dates of Service:
July 1, 2016- June 30, 2017
CBR Data Comparison Format
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Copy Pasting Cloning
Office of Inspector General OIG
Identical notations were noted for
different patients with different
problems. In several instances
language was exactly the same.
Most of the physical exam was
identical.
Inappropriate copy
pasting could inflate
claims to support billing
higher service levels.
Cloned documentation: it would not be expected the same patient had the same exact problem, symptoms, and required the exact same documentation on every encounter.
Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
CMS Contractor
Pitfall: Copy Pasting Cloning
Identical notations were noted for different patients with different problems. In several instances language was exactly the same. Most of the physical
exam was identical.
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Documentation Guidelines:Practical Application
Level HPI ROS PFSHx PE
1 1 0 0 1
2 1 1 0 2
3 1 1 0 2
4 4 2 1 5
5 4 10 2 8
The History and Acuity Caveats
“If the physician is unable
to obtain a history from the
patient or other source,
the record should describe
the patient’s condition or
other circumstances which
precludes obtaining a
history.”
CMS 1995 Documentation
Guidelines
▪ 99285 requires:
⎻ Comprehensive History
⎻ Comprehensive Exam
⎻ High Level Medical Decision Making
Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status
CPT 2019
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Documentation Best Practice:Defending the Patient’s Acuity
▪ Document a differential diagnosis:
‒ Chest pain: ACS, GERD, Pneumothorax, PE
▪ Clearly state co-morbidities
‒ IDDM, Htn, Lymphoma
▪ Be aware of diagnoses qualifying as high risk
‒ Abrupt change in mental status
• (seizure, TIA, weakness, numbness)
HPI – 52 year old obese male presents with upper epigastric
discomfort and a feeling of indigestion for the past 4 hours. He has
tried TUMS and Mylanta without relief. Associated signs and
symptoms include diaphoresis and nausea.
Medical Decision Making – CBC with differential, Chem 7, Troponin,
EKG and US of gallbladder. Reviewed nurses notes
Plan – Admit
Diagnosis – Chest pain
Auditor Downcoded to 99284:“lacks medical decision making”
No documentation of :
- risk with differential dx
- co-morbidities (HTN, smoker)
- old record review (old ekg)
- discussion w/ providers (Cards
and Hospitalist)
Had episode of chest pain in the ER
treated with SL NTG
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HPI: 68 year old with PMH of CAD HTn, and IDDM
With several days of worsening lower extremity swelling.
Also reports recent productive cough and low grade fever.
PE: Breath sounds + crackles bil bases, 2+ pitting edema to knees
DDx: ACS, CHF, pulmonary edema, pneumonia
MDM : CBC, CMP, BNP, Troponin, EKG, CXR obtained. EKG interpretation by ED
provider: septal infarct age undetermined, CXR interpretation by ED provider: bil.
baslar infiltrates, BNP elevated at 864, Troponin neg.
ED Course: Treated with Lasix 80 mg IV and MSO4 2 mg IV
BS 385 (Tx SQ Insulin)
Old record reviewed with summary- Previous admission last May for Pneumonia
and renal insufficiency
Case discussed with DR XXX (IM/Cardiology) for admission with continuity of care
Final Diagnosis- CHF, Pneumonia
99285 Upheld
Extensive diff dx & high risk conditions
Extensive Data
Ongoing Additional
Tx
Comorbidity
High risk medication
▪ 4 HPI for most presentations
▪ Small or large macro for ROS and PE
depending on complexity
▪ Differential Diagnosis
▪ Course of care and responses to
treatment
▪ Review of data: labs, EKG, CXR, old
record
▪ Conversations: EMS, Family, PCP,
Hospitalist
The Defense
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“Students may document services in the medical record.
However, the teaching physician must verify in the medical
record all student documentation or findings, including
history, physical exam and/or medical decision making.
The teaching physician must personally perform (or re-
perform) the physical exam and medical decision making
activities of the E/M service being billed, but may verify any
student documentation of them in the medical record,