Billing, Coding, Credentialing, Contracting, and Reimbursement

Transcription

1 Billing, Coding, Credentialing, Contracting, and Reimbursement Bopanna B. Ballachanda, Ph.D. Audiology Consultant Albuquerque, NM Distinguished speaker Kris R. Kwolek Partner at Husch Blackwell s Law firm J.D., University of Texas at Austin School of Law, B.S., Texas A&M University, Direct: Kris.Kwolek@huschblackwell.com Ancillary Service Providers Healthcare Audit Defense Healthcare Compliance Counseling and Defense Healthcare Fraud & Abuse Healthcare Insolvency & Bankruptcy Healthcare Investigations and Government Enforcement Healthcare Operations Hospitals & Health Systems PRACTICE AREAS Intellectual Property Life Sciences Life Sciences IP Life Sciences Licensing and Tech Transfer Medicaid Reimbursement Strategies Medicare Advantage Patents Physicians & Other Professionals Pharmacy Pharmacy Benefit Managers Post-Acute Care Providers Disclaimer Presenter is receiving an honorarium and travel support from the Association Presenter has no relevant non-financial relationships to disclose. The purpose of this presentation is to inform and educate the members, the presenter does not take any responsibility for the consequences by the use of this information by any individual. I am not a biller or coder 4 1

2 Presentation Topics OPERATING COST: Learn how much it cost to operate a clinic CALCULATING FEES: Learn how to determine fees for your services CODING: Learn the codes that describe the services you provide. What is new in Medicare - MACRA CONTRACTING: How to establish a contracting with various payors? REIMBURSEMENT: How to get reimbursement BILLING: case studies of billing issues CREDENTIALING: What is credentialing? DENIAL AND APPEAL: How to read denial and the appeal process Compliance and Red Flags Audiology is a Business It Is More Than Just Being a Good Clinician Is It Time To Reassess Business Practices? What is your profit margin for cost of goods? Cost of doing business? When was the last time you reviewed a fee schedule, the reimbursement levels, and utilization numbers for a health plan? How does it relate to the cost of doing business? Minding the Business Reimbursement is the multi-faceted foundation for sound practice management Must know the language Must utilize best coding and billing practices Have you Negotiated good insurance contracts? Are your third party contracts profitable? Are they what was originally negotiated? Have you re-negotiated periodically? 2

3 Operating cost How to Calculate Hourly Rates How much does it cost to run a practice? Any practice Private or Funded Annual Expense Annual Contact Hours =Rate Profit and Loss Formula Profit or Loss : Revenue Expenses = Profit (Loss) How to determine the number of hours Copy of Calculating TAA.xlsx Annual Expenses + Desired Profit_ Annual Contact Hours = Rate/Hour 3

4 Revenue-Expense at Your Clinic Revenue (Income) Tests Hearing aid sales Therapies/Consultation Others (Accessories) Expenses Cost of goods sold Salaries and benefits Clinic related Rent Incidentals - Equipment (leased or loan/interest) Others (Travel, etc.) A Challenge You write the case for a 55 year old male with a bilateral symmetrical SNHL who was fit with bilateral hearing aids with a remote microphone and coupled using custom earmolds (not domes). (1.comprehensive audio + 2. immittance); visit to a physician for 3. medical clearance because the patient had 4.asymmetry SN loss and 5.unilateral tinnitus (also got an 6.ABR and 7.MRI and results were negative for 8 th nerve). He came back for the 8.HAE where I did 9.unaided QuickSIN, 10.LDL s as well as 11.unaided COSI. I also made 12.impressions to order earmolds and 13. ordered the aids (Selection). I did a 14. hearing aid fit 2 weeks later using 15. real ear measures, 16. aided LDLS for speech and pure-tone sweep RESR90) and 17.aided QuickSIN. 18.Counseled and patient 19.returned 6 weeks later to let me know he loves the aids (why wouldn t he) and I did some fine-tuning to address some loudness and sound quality issues and he completed the 20. aided COSI. Itemization of clinic services ItemizedBilling.xlsx Reimbursement: CODING: Learn the codes that describe the services you provide. Use these codes to communicate with health plans Must know the language BILLING; Billing the Proper Code: Learn how to bill for your services 4

5 National Provider Identifiers (NPIs) The NPI is the health care provider identification system adopted by the U.S. Department of Health and Human Services as part of the implementation of HIPAA. All health care providers that are considered covered entities under HIPAA, and those who file claims electronically or use a clearinghouse to bill insurance, are required to apply for an NPI. All other health care providers are eligible to receive an NPI if they desire. Audiologists and speech-language pathologists can apply online for their NPI, free of charge, at: Credentialing We encourage you to submit an application, attestation and authorization form using the Council for Affordable Quality Health Care (CAQH) Universal Credentialing DataSource application at CAQH CORE: Operating Rules to Drive the Business of Healthcare Established in 2005, CAQH CORE is a multi-stakeholder collaboration of more than 130 organizations providers, health plans, vendors, government agencies, and standardsetting bodies developing operating rules to simplify healthcare administrative transactions. CAQH CORE participating organizations include health plans representing more than 75% of commercially insured lives, plus Medicare and Medicaid beneficiaries. Operating rules support a range of existing standards to make electronic data transactions more predictable and consistent, regardless of the technology. Operating rules facilitate many high-volume transactions that involve multiple parties, such as automated banking transactions and airline ticket bookings. The CORE process centers on an integrated model consisting of: rule development, testing and certification, and measure tracking/outreach. A voluntary CORE Certification program drives value and return on investment for all trading partners by ensuring the rules are used consistently; thereby encouraging broader use of the rules. Health plans, providers, vendor/clearinghouses that create, transmit or use administrative data may become CORE-certified. CAQH CORE has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for federally mandated operating rules per Section 1104 of the Patient Protection and Affordable Care Act (ACA). Credentialing, Contracting, Billing, Coding, and Reimbursement CPT Codes Procedural Codes ICD-10 Codes Diagnostic Codes HCPCS Codes - Service Codes 5

6 CPT Codes Procedural Codes Audiology Diagnostic Procedures Tympanogram and reflex threshold measurements Screening, PT air only PT audio, threshold, air only Air and bone Speech audiometry, threshold Speech audiometry threshold with speech recognition Comp aud eval (92553 and combined) Stenger test, PT Tympanometry Acoustic reflex testing, threshold Acoustic immittance testing (tymps, ART, ARD) Staggered spondaic word test Synthetic sentence identification test Stenger test, speech Visual reinforcement audiometry Conditioned play audiometry Auditory evoked potentials, comprehensive Auditory evoked potentials, limited OAEs, limited OAEs, comprehensive Evaluation of central auditory function, with report, initial 60 min Each additional 15 minutes (must bill with 92620) Assess of tinnitus (pitch, loudness matching, masking Hearing aid Procedure Codes Hearing aid exam and selection, monaural Hearing aid exam and selection, binaural Hearing aid check, monaural Hearing aid check, binaural Electroacoustic eval for hearing aid, monaural Electroacoustic eval for hearing aid, binaural Ear protector attenuation measurements Eval of aud rehab status, first hour Each additional 15 minutes (must bill with 92626) Aud rehab, prelingual HL Aud rehab, postlingual HL Unlisted otorhinolarngologicalsvc or procedure OTHER Cerumen removal VESTIBULAR TESTS AND REHABILITATION Basic vestibular eval (92541, 92542, 92544, 92545) Spont nystagmus test, gaze and fixation, w/ recording Positional nystagmus test, min of 4 positions, w/ recording 92537* Caloric vest test, with recording, bilateral; bithermal (4 irrigations) 92538* Caloric vest test, with recording, bilateral, monothermal (2 irrigations) OPK nystagmus, bidirectional, foveal or peripheral stim, w/ recording Oscillating track test, w/ recording Sinusoidal vertical axis rotational testing Use of vertical electrodes Comp dynamic posturography Canalith Repositioning Procedure Modifiers used with CPT codes Common Modifiers 22 Increased procedural service 26 PC, If you only interpret , 92548, 92585,92587 or Reduced services 59 Distinct procedural service (Use for 92541, 92542, or 92545), if reporting 1 3 of these codes individually TC If you only perform , 92548, 92585, or Medicare Modifiers GA GX Use with a mandatory Advanced Beneficiary Notice (ABN) for a covered service Use with a voluntary ABN for a noncovered service GZ The provider or supplier expects a medical necessity denial; however, did not provide an ABN to the patient GX & GY May be utilized for non-covered services GY Use for a statutorily excluded service (often used when a denial from Medicare is necessary for a secondary payor) 6

7 Question Answer Question : CPT stands for: a) Clinical Practice Terminology b) Clinical Procedural Terminology c) Certified Procedural Technology d) Clinical Procedural Technology Question : CPT stands for: a) Clinical Practice Terminology b) Clinical Procedural Terminology c) Certified Procedural Technology d) Clinical Procedural Technology Evaluation and Management Code These are the codes physicians and non-physician practitioners (such as nurse practitioners and physician assistants) utilize to bill for office visits. Per the CPT manual, these codes can be used by qualified health professionals who are authorized to perform such services within the scope of their practice. Please note: Most E/M code descriptions (except 99211) contain the term physician. As a result, use of these codes does contain some level of risk. Common codes to be considered by audiologists are: and Avoid and as inappropriate for audiologists as this level of code requires a high risk of morbidity and mortality (which otologic issues do not contain). It is important to inform the audiologists about use of evaluation and management (E&M) codes. It is important the E&M codes are within the scope of licensure law in the state of practice and the contract states that billing E&M codes are reimbursable with appropriate documentation by the third party payors. It is also important to remember that the E&M codes should be billed to all payors including Medicare (even though it is a noncovered item). As a cautionary note, do not use E&M codes for hearing aid check and visits, also do not use it when it was used by another provider (e.g., ENT or hospital setting where it was billed by others on the same day). Pediatric Case Study 7

8 CPT Codes used for Pediatric Assessment and follow up: Case Example : Child 12 months old was recommended for hearing evaluation and follow up. Hearing evaluation: Few important things to remember while billing pediatric evaluation are: 1) Use codes that represents the procedure performed; 2) Document the child s medical history to support the reasons for performing various tests and the codes that was used for billing. CPT Codes used for Pediatric Assessment and follow up: Visual Reinforcement Audiometry: 92579: Above 6 months Conditioned Play Audiometry: 92582: At age three years and above Clinician should perform if applicable: Speech threshold audiometry (92555) Picture Audiometry (92583) Or Speech Audiometry Threshold with Speech Recognition (92556). Assessment of middle ear and inner ear status: CPT codes associated with tests for middle ear evaluation: Tympanometry (92567); Acoustic Reflex Threshold Testing (92568); or Combined Tympanometry and Reflex Threshold Measurements (92550), Acoustic Immittance testing, which includes Tympanometry, Acoustic Reflex Threshold Testing and Acoustic Reflex Decay Testing (92570). If a Pediatric Audiologist performs 1,000 Hz ipsilateral acoustic reflex screening, there is no CPT code for this procedure. In this case, the Tympanometry code (92567) can be used. Question CPT code Acoustic Immittance testing: a)tympanometry, Acoustic reflex threshold and reflex decay b)tympanometry, ipsilateral reflex threshold and decay c) Pure tone threshold, acoustic reflex threshold and speech testing d) None of the above 8

9 Assessment of Inner ear and lower brainstem Evaluation: OAE screening code (92558) should be billed when an overall pass/fail result is obtained and no additional interpretation is performed. The OAE limited evaluation code (92587) should be used when the purpose of the test is to evaluate hearing status specifies that three to six OAE frequencies should be evaluated per ear. The OAE comprehensive evaluation code (92588) should be used when evaluating 12 or more OAE frequencies per ear. The Limited Auditory Evoked Potential code (92586) is generally used by Universal Newborn Hearing Screening (UNHS) programs for screening. The comprehensive Auditory Evoked Potential code (92585) should be used for all other auditory evoked response testing, including testing via air and bone conduction. Currently, there is not a CPT code that differentiates threshold-search auditory brainstem response (ABR) from diagnostic ABR. Answer CPT code Acoustic Immittance testing: a)tympanometry, Acoustic reflex threshold and reflex decay b)tympanometry, ipsilateral reflex threshold and decay c) Pure tone threshold, acoustic reflex threshold and speech testing d) None of the above CPT Codes used for Vestibular Assessment and follow up: Vestibular Assessment If the canal is impacted with cerumen (H61.20, H61.21, H61.22, H61.23), it should be removed in order to complete caloric testing (69210). Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording. In case the clinician performed all these tests then it should be reported under one code (92540). 9

10 Caloric Testing: Caloric vestibular test, each irrigation with recording (92537). The caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations) and (Caloric vestibular test with recording, bilateral; monothermal (i.e., one irrigation in each ear for a total of two irrigations). In the event that the clinician was not able to complete either the monothermal (92538) or bithermal (92537) and a modifier (- 52) should be used to reflect reduced testing. Rotary Chair: Sinusoidal vertical axis rotational testing must have rotational chair (92546). This test requires the use of a chair capable of rotating around a vertical axis. This code is NOT appropriate for substitute chairs or platforms or for VAT/VORTEQ or other active head-shake tests. Technically speaking, this is considered a contact code which only allows for billing of one unit per date of contact or service with the patient. This is regardless of whether multiple rotary chair procedures (such as sinusoidal harmonic acclerations, step velocity, off-axis and/or visual-vestibular interaction tests) are performed or if multiple frequencies are performed. There is no allowance to bill this code for more than one date of service though there are a few payers who will pay multiple units, though inappropriately. Posturography Computerized dynamic posturography - Need a platform (92548). This is a single unit code for billing purposes. Technically speaking, it s use is confined to computerized platforms (the original full descriptor states it must include SOT, MCT and EMG which is really only offered by one manufacturer, NeuroCom). The irony of this code is that it is one of the few codes that Medicare WILL pay but many private insurances do not. Typically most private insurers follow. Keep it simple and bill it as one unit and technically it should be performed using a computerized platform that is capable of SOT and MCT at minimum. Follow up. The follow up after vestibular and balance testing can lead to Canalith repositioning procedure(s) (eg Epley maneuver, Semont maneuver), 1 unit per day (95992). Diagnostic Codes ICD -10 for Ear Disease and Hearing loss. ICD-10-CM Organized in 21 chapters. Each chapter is uniquely identified by letter. 1st digit always alphabetic 2nd and 3rd digits always numeric 4th, 5th, and 6th digits may be letters or numbers, or may be a placeholder (x) There is always a decimal after the first three digits. First 3 digits define the code category Second three digits etiology, anatomical site, or severity Seventh digit extension describes the encounter type (initial, subsequent, sequela) for certain conditions such as TBI 40 10

11 ICD-10-CM TABULAR LIST of DISEASES and INJURIES 1 Certain infectious and parasitic diseases (A00-B99) 2 Neoplasms (C00-D49) 3 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 4 Endocrine, nutritional and metabolic diseases (E00-E89) 5 Mental, Behavioral and Neurodevelopmental disorders (F01-F99) 6 Diseases of the nervous system (G00-G99) 7 Diseases of the eye and adnexa (H00-H59) 8 Diseases of the ear and mastoid process (H60-H95) 9 Diseases of the circulatory system (I00-I99) 10 Diseases of the respiratory system (J00-J99) 11 Diseases of the digestive system (K00-K95) 12 Diseases of the skin and subcutaneous tissue (L00-L99) 13 Diseases of the musculoskeletal system and connective tissue (M00-M99) 14 Diseases of the genitourinary system (N00-N99) 15 Pregnancy, childbirth and the puerperium (O00-O9A) 16 Certain conditions originating in the perinatal period (P00-P96) 17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 19 Injury, poisoning and certain other consequences of external causes (S00-T88) 20 External causes of morbidity (V00-Y99) 21 Factors influencing health status and contact with health services (Z00-Z99) Question: ICD-10 codes belong to: Question a) American Medical Association b) Center for Disease Control c) World Health Organization d) Center for Medicare and Medicaid Services 41 Question: ICD-10 codes belong to: Answer a) American Medical Association b) Center for Disease Control c) World Health Organization d) Center for Medicare and Medicaid Services ICD-10-CM Official Guidelines for Coding and Reporting Section I. Conventions, general coding guidelines and chapter specific guidelines Section II. Selection of Principal Diagnosis Section III. Reporting Additional Diagnoses Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services Appendix I 105 Present on Admission Reporting Guidelines 44 11

12 ICD-10-CM Official Guidelines for Coding and Reporting Section I. Conventions, general coding guidelines and chapter specific guidelines A. Conventions for the ICD-10-CM 1. The Alphabetic Index and Tabular List 2. Format and Structure: The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A threecharacter category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character. The ICD-10-CM uses an indented format for ease in reference. A. Conventions for the ICD-10-CM 11 Includes: The word 'Includes' appears immediately under certain categories to further define, or give examples of, the content of the category. 12 Excludes Notes The ICD-10-CM has two types of excludes notes. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other. Excludes1 A type 1 Excludes note is a pure excludes. It means 'NOT CODED HERE!' An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Excludes2 A type 2 excludes note represents 'Not included here'. An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together Coding Laterality Chapter 8 in ICD-10-CM For bilateral conditions, the final character indicates laterality. 1 = RIGHT, 2 = LEFT, 3 = BILATERAL. Unspecified is coded as 0 or 9 There are exceptions: Bilateral conductive HL: H90.0 Unilateral conductive HL: H90.11 or H90.12 Bilateral SNHL: H90.3 Unilateral SNHL: H90.41 or H90.42 Bilateral mixed HL: H90.6 Unilateral mixed HL: H90.71 or H Every code starts with an H Organization: Diseases of external ear (H60-H62) Disorders of middle ear and mastoid (H65-H75) Diseases of inner ear (H80-H83) Other disorders of the ear (H90-H94) Intraoperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified (H95) Hearing loss is organized under Other Disorders of the Ear (H90-H95) 48 12

13 Other Chapters for additional information Other Chapters for additional information Conditions are not part of the coded in Chapter 8, but the patient may have both conditions at the same time. Certain conditions originating in the perinatal period (P04-P96) Certain infectious and parasitic diseases (A00-B99) Complications of pregnancy, childbirth and the puerperium (O00-O99) Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Endocrine, nutritional and metabolic diseases (E00-E88) Injury, poisoning and certain other consequences of external causes (S00-T88) Neoplasms (C00-D49) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) Note worthy information ICD-10 has given us the following Laterality (right, left, bilateral) New codes for unilateral and bilateral temporary threshold shift (H93.24-) New codes for ototoxic hearing loss (H91.0-) New codes for intra-operative and post-procedural complications (H95) H91.8 Other specified hearing loss H91.8X Other specified hearing loss H91.8X1 Other specified hearing loss, right ear H91.8X2 Other specified hearing loss, left ear H91.8X3 Other specified hearing loss, bilateral H91.8X9 Other specified hearing loss, unspecified ear 51 13

14 How Do I Code Balance Disorders? H81.0- Ménière's disease H81.1 Benign paroxysmal vertigo H81.2-Vestibular neuronitis H Aural vertigo H Other peripheral vertigo H81.4- Central vertigo H81.8x- Other disorders of vestibular function H82- Vertiginous syndromes classified elsewhere H83.0- Labyrinthitis H83.1- Labyrinthine fistula H83.2x- Labyrinthine dysfunction Final character: 1 =right, 2 =left, 3 =bilateral, 0 or 9 = unspecified New Codes 2017 H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side H90.A2 Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side H90.A3 Mixed conductive and sensorineural hearing loss, unilateral with restricted hearing on the contralateral side H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side 53 Post-procedural Complications Code the complication code followed by the specific effect of the complication (e.g. hearing loss). Additional Codes for Audiology Diagnosis H95.31 Accidental puncture and laceration of the ear and mastoid process during a procedure on the ear and mastoid process H95.41 Postprocedural hemorrhage and hematoma of ear and mastoid process following a procedure on the ear and mastoid process Example: Accidental TM perforation with hearing loss H95.31 H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

15 11/3/2017 Supplemental Codes Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Z codes are neither diagnoses or procedures. Used for circumstances other than a disease: When a person who may or may not be sick encounters the health services for some specific purpose, such as limited care or service for a current condition, to donate an organ or tissue, immunization, or to discuss a problem which is in itself not a disease or injury. When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Status and History Codes Status codes indicate that a patient has the sequelae or residual of a past disease or condition. Includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. Status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition. There are two types of history Z codes, personal and family. Personal history explains a patient s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Family history use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease Supplemental Codes Z02 Encounter for administrative examination Z02.0 Encounter for examination for admission to educational institution Z02.1 Encounter for pre-employment examination Z02.2 Encounter for examination for admission to residential institution Z02.3 Encounter for examination for recruitment to armed forces Z02.71 Encounter for disability determination Z03 Encounter for screening for other diseases and disorders Z13.5 Encounter for screening for eye and ear disorders Z Encounter for screening for traumatic brain injury Supplemental Codes Encounter for other special examination without complaint, suspected or reported diagnosis Z01.10 Encounter for examination of ears and hearing without abnormal findings Z Encounter for hearing examination following failed hearing screening. New born hearing evaluation and get paid for this diagnosis. Z Encounter for examination of ears and hearing with other abnormal findings Use additional code to identify abnormal findings Z01.12 Encounter for hearing conservation and treatment

16 Supplemental Codes Z45 Encounter for adjustment and management of implanted device Z Encounter for adjustment and management of bone conduction device Z Encounter for adjustment and management of cochlear device Z Encounter for adjustment and management of other implanted hearing device Other Useful Codes Z46.1 Encounter for fitting and adjustment of hearing aid Z57.0 Occupational exposure to noise Z71.2 Person consulting for explanation of examination or test findings Z76.5 Malingerer (Person feigning illness with obvious motivation) Z Contact with and (suspected) exposure to noise Supplemental Codes Z83.52 Family history of ear disorders Z86.69 Personal history of other diseases of the nervous system and sense organs Z96.20 Presence of otological and audiological implant, unspecified Z96.21 Cochlear implant status Z96.22 Myringotomy tube(s) status Z96.29 Presence of other otological and audiological implants Z97.4 Presence of external hearing-aid Coding a visit: Basics Code for the reason for the visit (Medicare transmittal 84) Code with signs and/or symptoms Why the patient presented to your office? Code by patient history/complaints (Medical Necessity) Tinnitus Hearing loss Disequilibrium Code by findings SNHL? Tinnitus? Conductive hearing loss, middle ear? Question Question : Coding a finding is based on: a) Code for the reason for the visit b) Code with signs and/or symptoms c) patient history/complaints (Medical Necessity) d) All of the above 16

17 Answer Case 1 Presentation Question: Coding a finding is based on: a) Code for the reason for the visit b) Code with signs and/or symptoms C) patient history/complaints (Medical Necessity) d) All of the above 52 Year old male patient Chief complaint : Difficulty in hearing speech in noise. Remaining case history is unremarkable No report of dizziness, ear ache, pain, family history of hearing loss, noise exposure or any other complications. CPT code What would be the CPT code? CPT code What would be the CPT code? ?? 17

18 CPT code What would be the CPT code? Some requirement of the code were not performed but interpretation was the finding will not be affected. Question Question: Modifier 52 when attached with a CPT code reflects: a) Increased services b) Reduced services c) Services provided for children d) No service was provided Answer Question: Modifier 52 when attached with a CPT code reflects: a) Increased services b) Reduced services c) Services provided for children d) No service was provided Coding a visit: Basics Code for the reason for the visit (Medicare transmittal 84) Code with signs and/or symptoms Why the patient presented to your office? Code by patient history/complaints (Medical Necessity) Tinnitus Hearing loss Disequilibrium Code by findings SNHL? Tinnitus? Conductive hearing loss, middle ear? 18

19 How do we code this patient? Code based on test/procedural outcome? Normal findings Code based on symptoms? Code based on chief complaint? Code based on the reason for the visit? Patient reported difficulties in hearing speech in noise. What code to diagnose this patient? 1. H 90.3 Bilateral sensorineural loss? 2. H 90.5 Unspecified sensorineural loss? 3. H Other abnormal auditory perception Unspecified ear 4. Z01.10 Encounter for examination of ears and hearing without abnormal finding What code to diagnose this patient? New Codes H 90.3 Bilateral sensorineural loss? NO 2. H 90.5 Unspecified sensorineural loss? NO 3. H Other abnormal auditory perception Unspecified ear based on chief complaint 4. Z01.10 Encounter for examination of ears and hearing without abnormal finding. Not get paid. H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side H90.A2 Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side H90.A3 Mixed conductive and sensorineural hearing loss, unilateral with restricted hearing on the contralateral side H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side 19

20 How do we code this patient? H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side Additional References Credentialing, Contracting, Billing, Coding, and Reimbursement HCPCS Codes Service Codes S0618 Audiometry for HAE to determine the level and degree of HL V5008Hearing screening V5010Assessment for hearing aid V5011Fitting/orientation/checking of hearing aid V5014Repair/modification of a hearing aid V5020Conformity evaluation V5090Dispensing fee, unspecified hearing aid V5095Semi-implantable middle ear hearing prosthesis V5110Dispensing fee, bilateral V5120Binaural, body V5130Binaural, in the ear V5140Binaural, behind the ear V5160Dispensing fee, binaural V5170Hearing aid, CROS, in the ear V5180Hearing aid, CROS, behind the ear 20

21 V5200 V5210 V5220 V5240 V5241 V5244 V5245 V5246 V5247 V5250 V5251 Dispensing fee, CROS Hearing aid, BICROS, in the ear Hearing aid, BICROS, behind the ear Dispensing fee, BICROS Dispensing fee, monaural hearing aid, any type Hearing aid, digitally programmable analog, monaural, CIC Hearing aid, digitally programmable analog, monaural, ITC Hearing aid, digitally programmable analog, monaural, ITE Hearing aid, digitally programmable analog, monaural, BTE Hearing aid, digitally programmable analog, binaural, CIC Hearing aid, digitally programmable analog, binaural, ITC V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 Hearing aid, digitally programmable, binaural, ITE Hearing aid, digitally programmable, binaural, BTE Hearing aid, digital, monaural, CIC Hearing aid, digital, monaural, ITC Hearing aid, digital, monaural, ITE Hearing aid, digital, monaural, BTE Hearing aid, digital, binaural, CIC Hearing aid, digital, binaural, ITC Hearing aid, digital, binaural, ITE Hearing aid, digital, binaural, BTE Hearing aid, disposable, any type, monaural Hearing aid, disposable, any type, binaural V5264 V5265 V5266 V5267 V5268 V5269 V5270 V5271 V5272 V5273 V5274 V5275 V5298 V5299 Ear mold/insert, not disposable, any type Ear mold/insert, disposable, any type Battery for use in hearing device Hearing aid supplies/accessories Assistive listening device, telephone amplifier, any type Assistive listening device, alerting, any type Assistive listening device, television amplifier, any type Assistive listening device, television caption decoder Assistive listening device, TDD Assistive listening device, for use with cochlear implant Assistive listening device, not otherwise specified Ear impression, each Hearing aid, not otherwise classified Hearing service, miscellaneous Question Question: HCPCS service code V5160 indicates: a) Dispensing fee, binaural b) Dispensing fee, monaural c) Dispensing fee assistive listening devices d) Dispensing fee OTC 21

22 Answer Question: HCPCS service code V5160 indicates: a) Dispensing fee, binaural b) Dispensing fee, monaural c) Dispensing fee assistive listening devices d) Dispensing fee OTC Standardized Billing Form: The CMS 1500 What is MACRA MACRA is the Medicare Access & CHIP Reauthorization Act also know colloquially as the permanent doc fix. Although MACRA is know for repealing the Sustainable Growth Rate (SGR) provisions that would have significantly cut physicians salaries (but was reversed every December), there are other provisions. Medicare Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. Established in 1997 to control the cost of Medicare payments to physicians IF The Sustainable Growth Rate (SGR) Overall Target Medicare Physician payment cut physician costs expenditures across board Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians 22

23 MACRA PQRS Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population. Two tracks to choose from: one or the other Advance Alternative Payment Models (APMS) If you decide to enroll in this program you may earn Medicare incentive payment The Merit-based Incentive Payment System (MIPS) You man earn performance-based payment adjustment through MIPS Note: 2016 was the last program year for PQRS. PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March The first MIPS performance period is January through December 2017 Medicare Payment Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. Quality Payment Program Repeals the Sustainable Growth Rate (SGR) Formula Streamlines multiple quality reporting programs into the Merit-based Incentive Payment System (MIPS) Provides incentive payments for participation in Advanced Alternative Payment Models (APMs) new The Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) First step to a fresh start We re listening and help is available A better, smarter Medicare for healthier people Pay for what works to create a Medicare that is enduring Health information needs to be open, flexible, and user-centric 23

24 Resource Use 10% CLINICAL PRACTICE IMPROVEMENT ACTIVITIES 15% QUALITY 50% ADVANCING CARE INFORMATION 25% 24

25 QUESTIONS 25