Pdcast Transcript Title: Cmmn Miscding f LARC Services Impacting Revenue Speaker Name: Ann Finn Duratin: 00:16:10 NCTCFP: Welcme t this pdcast spnsred by the Natinal Clinical Training Center fr Family Planning. The Natinal Clinical Training Center fr Family Planning is ne f the training centers funded thrugh the Office f Ppulatin Affairs t prvide training t enhance the knwledge f family planning staff. Our guest speaker tday, is Ann Finn frm Ann Finn Cnsulting LLC. Ann will be talking abut the cmmn miscding f LARC services impacting revenue. Ann Finn is a healthcare reimbursement cnsultant and a natinal trainer with many reprductive Health Care rganizatins. Welcme, Ann! AF: Thank yu very much fr the intrductin and thanks fr jining us. Tday s pdcast will fcus n cmmnly miscded LARC r lng acting reversible cntraceptive services, which include IUDs and Implants. Imprper cding f services may lead t a reductin in reimbursement OR an unintended ver-payment f services which may pen a prvider t payer audits and payment take-backs when billing fr services. Bth are detrimental t a practice s fiscal health. When cding and billing fr LARC services, we need t first - prperly and fully dcument the services prvided during the clinical visit. Did the patient present seeking cntraceptin but was nt sure what birth cntrl methd is a best fit? Did she present wanting an IUD r an implant - based n her prir knwledge, research r cunseling received in anther setting such as her primary care visit? Or did she present fr a scheduled LARC insertin prcedure after receiving cntraceptive cunseling n a prir date? Each f these services frequently takes place in a busy family planning clinic and each scenari wuld be cded and typically reimbursed differently. Let s start with the first scenari: Maggie is a 19 year ld female patient wh recently became sexually active. She has had unprtected sex since her last menstrual perid and is wrried abut an unintended pregnancy. Maggie is nt sure what methd f cntraceptin she wuld like s she and her clinical prvider discuss the variety f methds available, their effectiveness and ptential side effects. During her visit, Maggie has her vitals taken but a further exam is deferred. The majrity f time during the clinical visit is spent cunseling. June 29, 2016 1
After discussing these ptins, Maggie decides she wuld like an IUD. Maggie is given a urine pregnancy test, which is negative. The prvider is able then t successfully insert the IUD. What cdes wuld we need t bill this visit and where d we see miscding? First we need t capture the cntraceptive cunseling service and tell the payer it is separate and distinct frm the actual LARC insertin prcedure. Depending n the extent f services prvided and cdes the payer accepts, the clinician may cde a preventive evaluatin and management r E/M cde, a prblem-riented E/M cde r a preventive cunseling cde fr the ptins cunseling. E/M visit cdes are dependent n whether a patient is new t yur practice r established and new patient visits are typically reimbursed at a higher rate than an established patient. What defines new t yur practice? Accrding t the Current Prcedural Terminlgy r CPT instructins, a new patient is ne wh has NOT received any prfessinal services frm the physician r qualified health care prfessinal r anther physician r qualified health care prfessinal f the exact same specialty and subspecialty wh belngs t the same grup practice, within the past three years. This includes prir face-t-face services such as an E/M r surgical prcedure. Imprper cding f new vs. established patient s impacts payment s it is critical t ensure accuracy here. Hw des a clinician in yur practice knw if the patient is new r established when cding a visit? Preventive E/M cdes are als based n the patient s age during the visit, which must be dcumented. Prblem riented E/M cdes are assigned based n either 1) the 3 key cmpnents f a visit including: the Histry taken, examinatin dne and the medical decisin making invlved in the patient care r 2) n the amunt f time the clinician spends face-t-face with the patient when greater than 50% f this part f the visit is dcumented as cunseling. New patients require all 3 f the 3 key cmpnents be factred int picking the level f cde fr the visit whereas an established patient r ne wh has been seen within the last 3 years, nly requires 2 f the 3 key cmpnents. Let s think abut Maggie s visit as a new patient Our clinician dcuments a detailed histry and a mderate level f medical decisin making BUT the patient ONLY had her vitals taken with NO further exam dcumented. The IUD insertin is separate frm the E/M. This lw level prblem-fcused exam fr a new patient des nt qualify fr a cde higher than a level 1 utpatient visit r a 99201. BUT ur clinician spent a great deal f time cunseling the patient. T June 29, 2016 2
use time fr E/M assignment the clinician needs t dcument bth their ttal face-t-face time and that greater than 50% f the time was spent cunseling the patient. Based n using time, the E/M level MAY qualify fr a level 2 r 3 visit, leading t increased reimbursement since payers typically pay mre fr a higher level visit. Hw d we tell the payer the services were separate and distinct frm each ther and bth shuld be reimbursed? By using a MODIFIER cde which is a 2 digit cde we add t a CPT cde t tell a payer a special circumstance abut the service perfrmed. In Maggie s case, we wuld cde an E/M cde with a mdifier 25 t tell the payer it is separate and distinct frm the insertin prcedure, alng with the LARC insertin CPT cde, a cde fr the LARC device and the CPT cde fr the pint f care test dne such as the urine pregnancy test. Each f these CPT cdes shuld als have an assciated ICD-10 cde t tell the payer the WHY why did we perfrm these services? Withut the mdifier 25 n an E/M billed with a prcedure t alert the payer f 2 distinct services, the payer ften bundles the services tgether which leads t reduced reimbursement. Let s recap where we ptentially see miscding fr Maggie s visit: Missing cdes fr Maggie s visit we wuld need an E/M cde fr the cntraceptive cunseling PLUS a LARC prcedure cde PLUS the LARC device PLUS any pint f care tests dne during the visit t ensure full reimbursement. Over r under cding f E/M services based n new vs. established patient status. Over r under cding f E/M services based n 3 key cmpnents vs. cunseling time. E/M assignment based n time withut bth the ttal face-t-face time and that > 50% was spent cunseling the patient bth dcumented in the patient s chart. Missed mdifiers t tell the payer special circumstances. Lab tests perfrmed withut dcumented medical necessity. In Maggie s case, the clinician had nted unprtected sex s the clinician did a UPT test but nt all patients may need t have this test dne t start cntraceptin. Missing ICD-10 cdes t supprt the medical necessity f EACH service prvided such as a Z30 09 fr the cntraceptive ptins cunseling, a Z30.430 fr the IUD insertin and a Z32.02 fr the negative pregnancy test. Let s lk at ur secnd scenari. What if Maggie presents wanting an IUD r implant? Our clinician reviews the effectiveness f the methd and ptential side effects and inserts the LARC. Shuld the clinician reprt an E/M alng with the LARC June 29, 2016 3
insertin? In this case the answer is NO the E/M and cntraceptive cunseling was nt significant, and separate and distinct frm the IUD prcedure. Billing an E/M here wuld be a case f ver-reprting f services. Hw abut ur 3 rd scenari where Maggie presents fr a scheduled LARC insertin? Wuld we reprt an E/M with the LARC prcedure? Again the answer is NO the cntraceptive ptins cunseling tk place at a prir visit and was already billed. Billing an E/M here wuld als create an ver-reprting f services. What if Maggie presents t have a new IUD reinserted? IUD reinsertins require 2 CPT cdes t be reprted fr prper reimbursement. We wuld reprt bth CPT cde 58301 fr the IUD remval and then CPT cde 58300 fr the IUD reinsertin. What happens if we submit these cdes withut a mdifier t tell the payer we are reprting multiple prcedures? Withut a mdifier 51 r 59 fr multiple r distinct prcedures appended t the lwer paying service, the secnd prcedure typically bundles int the first prcedure and DOES NOT pay separately resulting in an underpayment. WITH the crrect mdifier appended, a secnd prcedure will typically pay 50% in additin t a full payment fr the first prcedure. Missed cdes fr remvals als mean missed revenue ensure there is a CPT cde reprted fr every service dcumented. Billing staff need t understand cding f services including mdifier usage and expected payment f services t ensure all missed revenue is recgnized and crrectly resubmitted t a payer in a timely manner. What if Maggie is having a LARC inserted and the clinician needs t stp the prcedure due t the patient having a prblem such as severe pain r the device is unusable? In bth these cases we wuld still bill fr the prcedure but again we need a mdifier t tell the payer hey we attempted the prcedure, did a lt f the wrk, but needed t stp. By appending a mdifier 52 r 53 fr a reduced service t the LARC prcedure CPT cde and cding ICD-10 cde t explain any cmplicatins, a payer may ften reimburse a significant prtin f the expected payment fr a failed insertin. If yu bill fr a full insertin and then the patient presents fr a secnd attempted insertin at the fllwing visit, a payer may reject the 2 nd claim in full as a duplicate service. Nt all payers will reimburse fr multiple devices s check with the payer fr their plicies alng with cntacting the manufacturer fr a replacement device. Unlike IUDs, implants have a unique CPT cde fr an insertin (11981), a remval June 29, 2016 4
(11982) AND a reinsertin (CPT 11983). Unlike ICD-9, ICD-10 currently has n unique cdes fr implants. There is still sme cnfusin abut the crrect cdes t use fr implants. Fr implant r Nexplann insertins, we wuld cde CPT cde 11981 alng with ICD-10 cde Z30.018 fr initiating ther cntraceptives. Fr remvals and reinsertins, we wuld cde the CPT cde 11982 r 11983 alng with ICD-10 cde Z30.49 Remember Z30.018 and Z30.49 are nt unique t implants as under ICD-9 but is a shared cde with ther cntraceptives such as vaginal rings, hrmne patches and ther barrier methds. What abut the LARC device? There are currently 4 types f IUDs and 4 unique device HCPCS cdes: J7300 describes the cpper Paragard IUD, J7397 fr Liletta IUD, J7298 describes the Mirena IUD and finally J7301 fr the Skyla brand. Device cde J7302 which was previusly used fr the Mirena AND the Liletta IUD was deleted as an active cde as f January 1, 2016. If yu bill J7302 nw yu will mst likely receive n reimbursement fr the device. Make sure that cde is nt active in yur billing systems. If the clinician is using a device frm their stck and the device was NOT gtten specifically thrugh a pharmacy benefit fr the unique patient and already billed by a pharmacy t the payer, the device wuld be included n the visit claim. Missing device = missed revenue Under-reprting f a charge amunt vs. the anticipated cntracted amunt allwed fr the device by a payer will als result in missed revenue Devices are expensive and any missed payments r denials shuld be a tp pririty fr billing reslutin Billing staff shuld audit LARC insertins fr a 1:1 match fr every insertin there is a device accunted fr! Call yu payer a representative fr further guidance r clarificatin if yu dn t understand why a service r device is unpaid. We hpe these tips will help yu avid cmmn cding missteps impacting yur reimbursement f LARC services. Remember dcument all services prvided, accurately cde the services n the claim and submit t yur payers in a timely manner t ensure prper and full reimbursement f LARC services. Thanks fr jining us tday. NCTCFP: Thank yu Ann fr this infrmatin. Fr mre training infrmatin and resurces n cding in family planning settings, please visit the Natinal Training Centers website at www.fpntc.rg r call the Natinal Clinical Training Center fr Family Planning at 1-866-91-CTCFP, that s 1-866-912-8237. Thank yu. June 29, 2016 5