Medical Oncology Reimbursement for Newbies

Medical Oncology Reimbursement for Newbies

Agenda Introduction ICD- 10- CM Guidelines in Oncology Drug Administration Coding Drug Coding New Drugs Audits

Disclaimer ÊPayers differ on their guidelines. Please verify coding for each payer and claim. ÊThis is not legal or payment advice. ÊThis content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. ÊThis information is good for the date of the information and may contain typographical errors. ÊCPT is the trademark for the American Medical Association. All Rights Reserved. ÊAll denial data is from onpoint s proprietary database, focalpoint

Introduction What s different about Medical Oncology? It s all about the drugs Then, drug administration E/M is an afterthought It s all about Medicare regulations Incident to is key to avoiding investigations and penalties Drug Regulations are changing and evolving

What You Need To Know

Chapter 15, Section 60.1 INCIDENT TO Provision Charges for such services and supplies must be included in the physicians bills. (See 50 regarding coverage of drugs and biologicals under this provision.) To be covered, supplies, including drugs and biologicals, must represent an expense to the physician or legal entity billing for he services or supplies. For example, where a patient purchases a drug and the physician administers it, the cost of the drug is not covered. However, the administration of the drug, regardless of the source, is a service that represents an expense to the physician. Therefore, administration of the drug is payable if the drug would have been covered if the physician purchased it. 6

Chapter 15, Section 60.1.B Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel. Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies. 7

Chapter 15, Section 60.1.B Thus, where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician s service if there is a physician s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician. This does not mean, however, that to be considered incident to, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. 8

Chapter 15, Section 60.1.B Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services. Biggest compliance issue in Medical Oncology!!! 9

Chapter 15. Section 60.2 Nonetheless, in order for services of a non- physician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in 60 through 60.1. A non- physician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see 190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant s or nurse practitioner s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician s personal in- office service. As explained in 60.1, this does not mean that each occasion of an incidental service performed by a non- physician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non- physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. 10

Two Different Billing Scenarios Direct Billing Certain NP Practitioners can be credentialed and can bill under their own provider number Nurse Practitioners, Physician s Assistants, Certified Nurse Specialists, Clinical Psychologists, Medicare reimburses on a percentage (85%) of the Physician Fee Schedule Incident- to Billing Physician directed team Service is billed under physician s provider number

Direct Billing Criteria for Medicare Non- Physician Practitioner bills services directly to Medicare Must meet Medicare s credentialing requirements Can bill in any setting allowable under scope of practice (office, inpatient and outpatient hospital, etc)

Direct Billing Criteria for Medicare Can provide any services allowed under their scope of practice, but will only be reimbursed for covered services. Should have a collaborative agreement with physician or group of physicians May not ever have been excluded from a Federal program this should be part of the hiring process May be a contractor

Please note: Diagnostic testing rules have a different set of regulations and supervision levels

Incident- to Requirements Integral though incidental part of physician s professional service Commonly rendered without charge or included in the physician's bill Of a type commonly furnished in office/clinic Furnished under direct supervision of the physician/group Source: Medicare Carrier s Manual, Part 3, Chapter 2, 2050.1

Part of Professional Service Service must be medically necessary Service must follow initial physician service Supervision alone is not a service Physician incurs overhead expense for service

Integral AND incidental Services and supplies commonly furnished in physician s offices are covered Where supplies are clearly of a type that a physician is not expected to have on hand in his/her office setting, or are of a type no considered medically appropriate to provide in the office, they are not covered under the incident- to provision Supplies, including drugs and biologicals must be an expense to the physician or legal entity billing. Example: Do not bill samples, research, or other free drugs Service must be medically necessary Physician performs subsequent service to show active management and participation

Commonly furnished in Physician s office or clinic Place of service MUST be office/clinic Generally no hospital or other settings For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare coverage of the services of physician- employed auxiliary personnel as services incident to physicians' services

Direct Personal Supervision Not part of same day physician service Not in same room Physician or other member of group practice must be present in suite Clinic exception

Direct Personal Supervision Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.

Direct Supervision If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than hospital or SNF), their services are covered incident to a physician's service only if there is direct supervision by the physician. Example: nurse accompanied the physician on house calls and administered an injection, the nurse's services are covered. If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision.

Supervising vs. Ordering Physician In a group practice, where one physician orders a treatment/service to be performed by ancillary personnel under the supervision of a different physician who is a member of the group practice, the service should be billed under the provider number & name of the supervising physician who was present in the office when the service was provided NOT under the ordering physician.

Supervising vs Ordering cont. Example: Oncologist orders chemo to be given by a nurse while he/she is not present in the office, but under supervision of another physician member of the same group. Service should be billed under the name of the supervising physician

Supervising vs. Ordering cont. Example #2 Patient with high blood pressure. At first visit, treatment plan is established that the patient will come in once per week for a PT check. Patient sees a nurse for these weekly visits. This service is billed under the physician supervising the day that the patient is seen in the office.

Incident- to Versus Direct Billing Incident To No New Patients No New Problems Physician In Suite Not at Hospital or SNF Physician Directs Patient Care Full Payment Direct Billing Any Patient Any Problem Physician Playing Golf Any Place of Service NPP Directs Patient Care 85% of Physician Fee

Private Insurance and Managed Care Companies may have different policies and requirements!! Some insurance companies do not allow incident- to or billing under the doctor. Know your most common payer requirements

For Oncology/ Cancer

ICD- 10 Provider Impact Clinical documentation is the foundation of successful ICD- 10 Implementation Golden Rule of Documentation If it isn t documented by the physician, it didn t happen If it didn t happen, it can t be billed The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient what services were rendered and what is the severity of illness The key word is SPECIFICITY Granularity Laterality Complete and concise documentation allows for accurate coding and reimbursement 28

Best Documentation Practices 1. Always document diagnoses that contributed to the reason for an encounter, not just the presenting symptoms 2. Do not use follow up as a chief complaint it is specifically not a diagnosis 3. Document diagnoses, rather that descriptors 4. Indicate acuity/severity of all diagnoses 5. Link all diseases/diagnoses to their underlying cause 6. Indicate suspected, possible, or rule out when treating a condition as if it was known 7. Use supporting documentation from pharmacy, nursing, etc. 8. Avoid the use of symbols, non- standard abbreviations, circles, arrows, etc. 9. Address all problems considered in decision- making very important right now 10. Clarify the significance of diagnostic tests 29

ICD- 10 Provider Impact The 7 Key Documentation Elements: 1.Acuity acute versus chronic 2.Site be as specific as possible 3.Laterality right, left, bilateral for paired organs and anatomic sites 4.Etiology causative disease or contributory drug, chemical, or non- medicinal substance 5.Manifestations any other associated conditions 6.External Cause of Injury circumstances of the injury or accident and the place of occurrence 7.Signs & Symptoms clarify if related to a specific condition or disease process 30

ICD- 10 Documentation Tips Neoplasm Location Detailed location Left, Right, Bilateral May become mandatory this Fall Morphology Malignant, Benign Primary, Secondary In situ Uncertain behavior, Unspecified behavior Histology Identified by cytology, histology or pathology findings Stage / Metastatic Different, distinct locations Different primaries Metastatic sites 31

Neoplasm continued ICD- 10 Documentation Tips Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication? Treatment - surgery, chemotherapy, immunotherapy, radiation Adverse reaction of treatment neutropenic fever secondary to chemo Complication of the disease anemia due to malignancy Document if a complication is part of the disease process or an adverse effect of treatment Anemia due to malignancy or due to chemotherapy History of Malignancies previously removed and no longer receiving active treatment Clearly document for follow- up and medical surveillance 32

ICD- 10 Documentation Tips Breast Neoplasm in addition to information on previous slides, also include: Location Must include the quadrant of the breast Laterality right or left? Gender Specify clearly if patient is a male or female 33

ICD- 10 Documentation Tips Leukemia Acuity Acute, chronic Type Acute lymphoblastic Chronic lymphocytic Hairy cell Adult T- cell Disease Status Remission not achieved In remission In relapse 34

Lymphoma ICD- 10 Documentation Tips Classify based on histiologic type with lymph node, extranodal and solid organ involvement Hodgkin examples Nodular lymphocytic predominate Mixed cellularity classical Lymphocytic- rich classical Will change in 2017 starting October 1 Follicular examples Grade I IIIb Cutaneous follicle center Diffuse follicle center Non- follicular examples Small B- cell Diffuse large B- cell Lymphoblastic Mature T/NK- Cell Mycosis fungoides Anaplastic large cell, ALK- 35

ICD- 10 Documentation Tips Anemia Type Nutritional iron deficiency, vitamin B12 deficiency Hemolytic enzyme disorder, thalassemia Acquired versus hereditary Aplastic drug induced, idiopathic Cause / Underlying disease Post hemorrhagic Drug induced Malignancy Manifestation of adverse effect or poisoning Example neoplasm, kidney disease Document if part of the disease process, or an adverse effect of treatment Anemia due to malignancy or chemotherapy 36

ICD- 10 Documentation Tips Sickle Cell Anemia Type Hb- SS Thalassemia HB- C Trait Sickle- cell crisis Specify with or without crisis If in crisis, document manifestations Acute chest syndrome Splenic sequestration 37

Coagulation Type ICD- 10 Documentation Tips Hemorrhagic Disorder Coagulation defect Cause Hereditary Acquired Document underlying or associated disease Specify medications or drug use affiliated with manifestations Hematuria due to Coumadin 38

ICD- 10 Documentation Tips Drug Under- dosing is a new code in ICD- 10- CM. It identifies situations in which a patient has taken less of a medication than prescribed by the physician. Intentional versus unintentional Documentation requirements include: The medical condition The patients reason for not taking the medication example financial reason Z91.120 Patient s intentional under dosing of medication due to financial hardship 39

ICD- 10- CM Conventions Format and Structure Index alphabetic listing Index to Diseases Index to External Causes of Injury Tabular List alphanumeric listing Categories, Subcategories and Codes All categories are 3 characters a three- character category that has no further subdivision is equivalent to a code 40

ICD- 9- CM CODE A - Category of code B - Etiology, anatomical site, and manifestation ICD- 10- CM CODE A - Category of code B - Etiology, anatomical site, and/or severity C - Extension 7 th character for obstetrics, injuries, and external causes of injury A B A B C41

ICD- 9- CM Structure Format Numeric or Alpha (E or V) Numeric VX 5E 2 X0 X2. X0 X0. Category Etiology, Anatomic Site, Manifestation 3 5 Characters 42

ICD- 10- CM Structure Format Alpha (Except U) 2-7 Numeric or Alpha Additional Characters. AMS X X3 X2. X0 X1 X0 AX Category Etiology, Anatomic Site, Severity 3 7 Characters Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury 43

A Good Thing About ICD- 10- CM C is for Cancer!!! 44

Neoplasms (C00- D49) Range Codes C00- C14 Malignant neoplasms of the lip, oral cavity, pharynx C15- C26 Digestive Organs C30- C39 Respiratory and inter- thoracic organs C40- C41 Bones and articular cartilage C43- C44 Skin C45- C49 Mesothelial and and soft tissue C50 Breast C51- C58 Female genital organs C60- C68 Male genital organs 45

Neoplasms (C00- D49) Range C64- C68 C69- C72 C73- C75 C76- C80 C81- C96 D00- D09 D10- D36 D37- D48 D49 Codes Malignant neoplasm of the urinary tract Eye, brain, central nervous system Thyroid and other endocrine glands Malignant neoplasms of ill- defined, secondary, and unspecified sites stated as presumed primary of the lymphoid, hematopoetic, and related tissue In situ neoplasms Benign neoplasms Neoplasms of uncertain behavior Neoplasms of unspecified behavior 46

In This Chapter, We Will Learn how to select a neoplasm Understand primary and secondary Understand sequencing of diagnose in cancer care Make decisions about Cancer of Unknown Primary Discuss History Of 47

Neoplasm Guidelines Many guidelines are the same as ICD- 9- CM, but there are differences. To properly code a neoplasm, it is necessary to determine (not too different) whether: It is malignant, benign, in situ or of uncertain behavior; In malignant neoplasms, any secondary or metastatic sites should be identified. To code properly the Index Neoplasm Table should be accessed EXCEPT: If the histology is mentioned in the code descriptor, e.g. adenoma or sarcoma 48

The Neoplasm Table The neoplasm table is more detailed Let s take an example Go to the Neoplasm Table, which is right after the Index in your book Look up MALIGNANT PRIMARY NEOPLASM OF THE HILUS OF THE LUNG Can you use that code? What is next? 49

What Is Not In The Table Codes by Histology Sarcoma, Adenoma Morphology codes, which are in a separate chapter and are not included on claims (ICD- O) SO, non- small cell lung cancer just a malignant neoplasm of the lung Lymphatic Cancers Look up in the Table Malignant Primary Neoplasm of the supraclavicular lymph node 50

Neoplasms What is UNCERTAIN BEHAVIOR? It is when the tumor cannot be classified as malignant, benign, or in situ This must be documented by a physician- - most probably a Pathologist If you do not have the record, query the physician 51

Neoplasms W/Overlapping Sites A primary malignancy that overlaps two or more contiguous sites should be coded to the subcategory and/or code.8 (overlapping lesion), unless the combination is specifically indexed elsewhere For multiple lesions of the same site that are NOT contiguous, e.g. tumors in different quadrants of the breast are coded separately 52

Neoplasm Guidelines Again, if the encounter is strictly for chemo, immunotherapy, or Radiation, those Z- codes should be coded as the principal diagnosis with the neoplasm as a secondary. No big change from today. The secondary neoplasm should be designated as the principal diagnosis, if treatment is directed there. 53

Treatment Directed At Malignancy If the treatment is directed at the malignancy, then the malignancy is coded FIRST But, if the encounter is for chemo, radiation, or immunotherapy, then assign Z51.- - code as the first- listed diagnosis For billing purposes, link the drug to the malignancy treated as the primary for that J-, Q-, or C- code 54

Example of Treatment of Secondary A patient was diagnosed with a malignant cancer of the pancreatic duct with metastasis to the liver. The patient is now being treated for the liver malignancy. ICD- 9- CM 197.7 Secondary malignant neoplasm of liver 157.3 Malignant neoplasm of pancreatic duct ICD- 10- CM C78.7 Secondary malignant neoplasm of liver C25.3 Malignant neoplasm of pancreatic duct 55

Not A Change: A Reminder Metastatic to Refers to the secondary neoplasm EXAMPLE Brain cancer metastatic to the lung Brain is primary; lung is secondary Metastatic from Refers to the primary neoplasm EXAMPLE bone cancer metastatic from the breast Bone is secondary; breast is primary 56

Neoplasm Complications: Anemia Anemia associated with malignancy is coded with the malignancy sequenced first and anemia second IF THE ENCOUNTER IS ONLY for the treatment of anemia. This is a major departure- - - we shall see what payers do with this. There is an instructional note in the anemia code (D63.0) to code first the malignancy let s go to the book and check it out Anemia associated with chemo or immunotherapy is coded and the treatment is only for anemia, the anemia code is sequenced first, followed by the neoplasm, and the the adverse event, e.g. T45.1X5- (Adverse effect of antineoplastic and immunosuppressive drug). Management of anemia associated with radiation is coded with anemia first, malignancy second, and Y84.2 third which is radiation causing an abnormal reaction in the patient. 57

Anemia Example A patient was diagnosed with a malignant neoplasm of the frontal lobe. The patient was also anemic due to the tumor as the patient had not received chemotherapy or RT. The patient s only treatment is IV iron for the anemia. C71.1 Malignant neoplasm of frontal lobe D63.0 Anemia in neoplastic disease Make note of this sequencing as opposed to anemia associated with chemo or Radiation 58

Neoplasm Complications Dehydration is coded first with the neoplasm second, if the dehydration is the only treatment or the reason for the visit. But, if the patient develops a complication during a chemo encounter, the Z- code is first and dehydration second. An encounter for pain management means that the pain is sequenced first and the malignancy second. Signs, symptoms, and abnormal findings cannot be used to replace malignancies as primary diagnosis, except as noted Pathological fractures are coded with the cancer first and the pathological fracture code second. 59

Dehydration Example A patient was admitted to the hospital with dehydration and has a malignancy to the ethmoidal sinus. ICD- 10- CM E86.0 Dehydration C31.1 Malignant neoplasm of ethmoidal sinus 60

Pain in Neoplastic Disease Code G89.3 is assigned to pain associated with any malignancy it can be related to, associated with, or as a direct result of the cancer When an encounter is for the control of the pain or management of the pain due to the malignancy, G89.3 may be the principal diagnosis The source of the pain, i.e. the cancer should be reported If pain is an incidental finding in treatment of the malignancy, it need not be coded first 61

Pain Example Ms. Rose Budd has a malignancy of the frontal lobe of the brain was in acute pain during her follow- up visit. The physician prescribed a narcotic drug to relieve the patient s head pain, That was the only treatment of the day. G89.3 Acute pain in neoplastic disease C71.1 Malignant neoplasm of frontal lobe 62

Pathological Fracture Example A patient was treated initially in the E.D. for a fracture of the right tibia. After X- Rays, it was found to be due to a neoplasm of the right tibia C76.51 Malignant neoplasm of right lower limb M84.561A Pathologic fracture of bone in neoplastic disease, right tibia, initial encounter (7 th digit) 63

Extent of the Malignancy When the reason for the encounter with the patient is to determine the extent of the malignancy (staging), or for a procedure such thoracentesis or paracentesis, the primary malignancy is sequenced first EVEN IF chemo or radiation is administered. So, this may be true if a patient comes in for staging and chemo, depending on documentation. 64

Personal History of When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of primary and secondary malignant neoplasm, should be used to indicate the former site of the malignancy if no related pathology is discovered. When a primary malignancy HAS BEEN excised but further treatment such as chemo, radiation or surgery is directed to the site, a primary malignancy code should be used until treatment ends. 65

Personal history of A 56- year- old male was seen in follow- up following removal of the prostate three years ago for a malignancy. Would you use Z85.46 Personal history of primary malignant neoplasm of prostate? When a primary malignancy has been excised but further treatment, such as an additional surgery, radiation therapy or chemotherapy is directed to that site, the primary malignancy code, not the Z85 code should be used until treatment is completed. 66

More Neoplasm Guidelines Malignancies of two or more contiguous sites should not be coded as one or the other without asking the physician. Use contiguous codes if they are there unless it is disseminated cancer. 67

Overlapping Site Example The patient is a 46- year- old heavy drinker with cancer of the colon and rectum at the rectosigmoid junction. Code C19 68

CUP Code C80, Malignant neoplasm without specification of site, equates to cancer, unspecified. It is also for disseminated cancer for which no source can be determined C80.0 Disseminated malignant neoplasm, unspecified C80.1 Malignant (primary) neoplasm, unspecified Notice the difference, but this is a definite improvement 69

CUP Example An unfortunate 29- year- female comes in with right lung metastases and an unknown primary treated today as breast cancer with chemotherapy. C80.1 C78.01 70

Sequencing of Malignancies Code these as primary diagnosis: Primary malignancy when the reason for the encounter is treatment of the primary malignancy Secondary malignancy when the reason for the encounter is for the secondary malignancy Malignant neoplasm in a pregnant woman is coded to O9A.1-, followed by the neoplasm code Encounter for treatment of complications of neoplasm is coded with the complication first, except anemia associated with the malignancy Pathological fracture treatment, the pathological fracture is coded first, unless the treatment is to the malignancy 71

More Neoplasm Guidelines http://www.cdc.gov/nchs/icd/icdcm.htm 72

Offices versus Hospitals CPT is the trademark for the American Medical Association. All Rights Reserved.

A Training Tool for New Staff: A Building Block Approach to Coding for Drug Administration A systematic approach for offices Why was the patient here in the office? What did we give them? How did we give it? How long did it take? FROM Dr. Laurence Martinelli s initial presentation regarding Drug Administration coding in 2006 This differs in the hospital 7/28/16 CPT Codes American Medical Association. All rights reserved. 74

Documentation Principals Physician order Medical necessity Route of administration Site of administration Start and stop times for each substance infused Volume and rate Substance given

Initial Group Each group has at least one initial service code: Initial Chemotherapy infusion 96413 (16 min up to 1 hr) Initial Chemotherapy injection 96409 Initial Therapeutic Infusion 96365 (16 min up to 90 min) Initial Therapeutic Push 96374 Initial Hydration 96360 (31 min up to 90 min) *Initial or first hour of infusion (therapeutic infusions) is from 16 to 90 minutes 76

Additional Service w/ New Substance Group Additional infusions/injection of a new substance will be coded with sequential (or concurrent)codes: sequential chemotherapy infusion 96417 (16 min up to 90 min) sequential chemotherapy injection 96411 sequential therapeutic infusion 96367(16 min up to 90 min) sequential therapeutic push 96375 sequential hydration 96361 (31 min up to 90 min) 77

Why are they here in the office? The reason for the visit Sick patient, needs hydration Chemotherapy administration, will also see provider Follow up visit, intractable nausea/vomiting, needs drug therapy This used to determine the initial infusion regardless of when it happens in the context of other infusions or injections. This approach is not true for hospital based cancer centers which utilize a hierarchy approach. 7/28/16 CPT Codes American Medical Association. All rights reserved. 78

Hospital Coding Hierarchy Rules ØChemotherapy services are primary to diagnostic, prophylactic, and therapeutic services ØDiagnostic, prophylactic, and therapeutic services are primary to hydration. ØInfusions are primary to pushes ØPushes are primary to injections

What did we give them? Separate hydration over 30 minutes? Anti- emetics or other drugs? Chemotherapy? This determines which category of administration code(s) to bill And don t forget to bill for the J- codes 7/28/16 CPT Codes American Medical Association. All rights reserved. 80

How did we give it? IV infusion? IV push? SC or IM injection? A combination? This determines which specific administration code(s) to bill and if there are concurrent, subsequent, and/or sequential services. 7/28/16 CPT Codes American Medical Association. All rights reserved. 81

How long did it take? or > 15 minutes (push vs. infusion) One hour Additional hours Round to nearest 30 minutes Same or different substance? Remember that infusion times are measured by when the infusate is actually running; pre- and post- infusion times are not included Documentation of start/stop times for each agent is recommended 7/28/16 CPT Codes American Medical Association. All rights reserved. 82

Code Descriptions Hydration, Therapeutic, Prophylactic, and Diagnostic/Injections and Infusions Diagnostic Injections and Infusions (Excludes Chemotherapy) v v v v Physician affirms the treatment plan and supervises the staff. If significant separately identifiable Evaluation and Management service is performed, the appropriate E/M service code, use modifier 25 in addition to 96360-96379. For same day E/M service a different diagnosis is not required. If you use these to facilitate the infusion or injection, the following services are not reported separately: a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes, and supplies For de- clotting a catheter or port, see 36593- - lots of folks leave this off their Superbills! Watch the unbundling do not use 36591-36592 with any other service that day. 7/28/16 CPT Codes American Medical Association. All rights reserved. 83

Code Descriptors Hydration, Therapeutic Injections and Infusions v When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. That does not mean you can use a drug administration code for each. v v v When administering multiple infusions, injections or combinations, only one initial service code should be reported, unless protocol requires that two separate IV sites must be used. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (e.g., the first IV push given subsequent to an initial one- hour infusion is reported using a subsequent IV push code). However, if a patient comes back for a separate session OR has separate lines, use - 59. When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. This can be called bag up/bag down or needle in/needle out depending upon when the substance goes in. But, you may not count prep time. 7/28/16 CPT Codes American Medical Association. All rights reserved. 84

Code Descriptors Hydration 96360 Intravenous infusion, hydration; initial, thirty- one minutes to one hour 96361 each additional hour, up to 8 hours (List separately in addition to code for primary procedure) v v v v v Codes 96360-96361 are intended to report a hydration IV infusion to consist of a pre- packaged fluid and electrolytes (e.g., normal saline, D5- ½ normal saline+30meq KCl/liter), but are not used to report infusion of drugs or other substances. Hydration is essentially watering the patient. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intra- service supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set- up, infusion typically entails little patient risk and thus little monitoring. No concurrent hydration may be billed. It may only be billed if it is separate or sequential from IV therapy. 96361 is used for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments. Also use it to identify hydration if provided as a secondary or subsequent service after a different initial service [96360, 96365, 96374, 96409, 96413] through the same IV access. Use - 59 to denote a separate sequential hydration over 30 minutes. 7/28/16 CPT Codes American Medical Association. All rights reserved. 85

Code Descriptors Therapeutic, Prophylactic, and Diagnostic Injections and Infusions v The fluid used to administer the drug(s) is incidental hydration and is not separately reportable. This means, with the exception of hydration infusions, fluids may not be separately billed. v These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra- service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. 7/28/16 CPT Codes American Medical Association. All rights reserved. 86

Code Descriptors Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 96367 additional sequential infusion, up to 1 hour (List separately in addition 96368 concurrent infusion (List separately in addition to code for primary procedure) to code for primary procedure) v v Report 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service after a different initial service. Report 96367 only once per sequential infusion of same infusate mix. 96368 is reported when multiple infusions are provided in separate bags simultaneously through a single line. Piggy backed drugs can be reported with 96368. Report 96368 only once per encounter and in conjunction with 96365,96366, 96413, 96416. AMA CPT Assistant, November 2007 says In order to report a concurrent administration, the drugs cannot simply be mixed in one bag; there must be more than one bag. 96368 is not billed for HOPDs 7/28/16 CPT Codes American Medical Association. All rights reserved. 87

Code Descriptors Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96373 intra- arterial v 96372 may not be reported unless there is direct physician supervision, according to CPT. CPT instructs you to use 99211 for an injection without the physician present. This is not to be done for Medicare patients, since incident to rules mean that direct supervision is always required. None of the above is true of hospitals. 7/28/16 CPT Codes American Medical Association. All rights reserved. 88

Code Descriptors Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 96374 intravenous push, single or initial substance/drug 96375 each additional sequential intravenous push of a new substance/ drug (List separately in addition to code for primary procedure) 96376 intravenous push of the same substance > 30 minutes past after a previous one in a facility (hospital) 96379 Unlisted therapeutic, prophylactic or diagnostic intravenous or intra- arterial injection or infusion. This replaces 90799. v Use 96374 for initial infusion of 15 minutes or less. v Use 96375 in conjunction with 96365, 96374, 96409, 96413 v Use 96375 to identify intravenous push or infusion of 15 minutes or less of a new substance/drug if provided as a secondary or subsequent service after a different initial service is provided. 7/28/16 CPT Codes American Medical Association. All rights reserved. 89

Code Descriptors q q q Chemotherapy And Other Highly Complex Drug or Highly Complex Biologic Agent Administration Chemotherapy administration codes 96401-96549 can be used for parenteral administration of non- radionuclide anti- neoplastic drugs; and also to anti- neoplastic agents provided for treatment of non- cancer diagnoses (e.g., cyclophosphamide for auto- immune conditions) or to administer substances such as monoclonal antibody agents and/or other biologic response modifiers. For Medicare, the drug list for 96401-96549 is Carrier- determined. The agents require physician work well beyond that of therapeutic drug agents. These services can be provided by any physician (not just Oncologists). Chemotherapy services are typically highly complex and require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight and intra- service supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues. 7/28/16 CPT Codes American Medical Association. All rights reserved. 90

Code Descriptors Chemotherapy Administration These are included services, if performed just to prepare for chemo a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes and supplies For declotting a catheter or port, please use 36593 along with the de- clotting agent. 7/28/16 CPT Codes American Medical Association. All rights reserved. 91

Code Descriptors Chemotherapy Administration Ø Ø Ø Report separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. The administration of medications (e.g., anti- emetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported using 96360, 96361, 96365, 96379 as appropriate. The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. Check with Medicare before adopting this policy for your Carrier. When administering multiple infusions, injections or combinations, only one "initial" service code should be reported, unless protocol requires that two separate IV sites must be used. The initial code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. But, if separate sessions or multiple lines are used, use - 59 to denote this. 7/28/16 CPT Codes American Medical Association. All rights reserved. 92

Code Descriptors Injection and Intravenous Infusion Chemotherapy 96409 intravenous, push technique, single or initial substance/drug 96411 intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) (Use 96411 in conjunction with 96409, 96413) These codes used for short chemotherapy infusions as well. Intravenous or intra- arterial push is defined as: a) an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or b) an infusion of 15 minutes or less. 7/28/16 CPT Codes American Medical Association. All rights reserved. 93

Code Descriptors Injection and Intravenous Infusion Chemotherapy 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 96415 each additional hour, 1 to 8 hours (List separately in addition to code for primary procedure) 96416 Initiation of a Prolonged infusion, requiting of a portable or implantable pump 96417 Each additional sequential infusion v v v Report 96361 to identify hydration over 30 minutes, or 96366, 96367, 96375 to identify therapeutic, prophylactic, or diagnostic drug infusion or injection, if provided as a secondary or subsequent service in association with 96413. Use 96415 for over 30 minutes into the next hour of chemotherapy. For infusions of 30 minutes or less into the following hour, do not report any infusion time. 96416 is often considered to be an initial service by payers by Check the CCI for modifier guidelines. Often, use of - 59 will help. 7/28/16 CPT Codes American Medical Association. All rights reserved. 94

Code Descriptors Concurrent chemo? v Due to evidence of current practice standards, there is no code for concurrent administration of chemotherapeutic drugs. Multiple drugs given at the same session are considered sequential using codes 96411 or 96417. CPT 2006: An Insider s View You must use an unlisted code (96549) if you believe that you are giving concurrent chemotherapy or complex biologic agent. Leucovorin or Mesna was not considered as chemotherapy by the Drug Administration Work Group of CPT. 7/28/16 CPT Codes American Medical Association. All rights reserved. 95

CPT 96369: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set- up and establishment of subcutaneous infusion site(s). v CMS Guidance: For infusions of 15 minutes or less, report with CPT code 96372 v Additional guidance: Not Used So Often Ø Involves the placement of multiple subcutaneous accesses to infuse immune globulin Ø Includes an infusion pump to administer the infusion 96

CPT 96370 CPT 96370: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour List separately in addition to code for primary procedure vadd- on code (+) = Must be reported with CPT code 96369 vfor infusions greater than 30 minutes beyond one hour increments 97

More CPT Codes! 96373: Therapeutic, prophylactic or diagnostic injection, intra- arterial 96374: Therapeutic, prophylactic or diagnostic injection; IV push, single or initial drug 98

96375: Therapeutic, prophylactic or diagnostic injection; each additional sequential IVP of a new (different) substance/drug List separately in addition to code for primary procedure Add- on code (+) 96374 + 96375 Code 96375 Can be a short infusion a push is not a push per CPT 99

Hospitals Only! CPT 96376: Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential IV push of the same substance/drug provided in a facility vcode cannot be reported if a push of the same substance or drug occurred within 30 minutes (pushes of same substance or drug must be 31 minutes apart) Ø Example: Four hourly IVPs of any drug (e.g. furosemide) would be reported as 96374 x 1 & 96376 x 3 as long as the time requirement is met Is the ORDER and timing of injections in the record? Was this medically necessary? 100

Using 96376 Correctly Report multiple individually prepared administrations as individual drug administrations. If the drug or substance is prepared one time and then administered in portions, report the administrations as only one administration (i.e. 96374 or 96375, depending). If the clinician administers a 2 nd, separately prepared same drug in portions, this would equal a single admin of the same drug beyond a 30- minute interval (CPT 96376), if the timing is correct 101

Question: How is the initial service selected in hospital outpatient departments? Answer: The initial code that best describes the key or primary reason for the encounter should always be reported regardless of the order in which the infusions or injections were given. vthis was not always clear in the past, but now the CPT book makes it explicit with a hierarchy! Ø Chemo infusions Ø Chemo injections Ø Non- chemo, therapeutic infusions Ø Non- chemo, therapeutic injections Ø Other injections Ø Hydration infusions 102

Selecting Initial, Sequential & Concurrent CPT Codes } Initial v Code that best describes the key or primary reason for the visit (offices) v One code in each category of IV infusion and IV push drug administration codes has been designated as the initial service v Order of service delivery does NOT determine what is initial v Only one initial service should be reported per encounter UNLESS: Ø Protocol requires two separate IV sites Ø Multiple encounters are provided on the same DOS Ø Other drug administration services are also provided by a different route other than IV infusion or IV push 103

} Sequential/Subsequent vadd- on codes ( one after another or before or after the initial drug service ) Ø Should be used in addition to an initial code and the order of the services given does not matter Ø Reported once per encounter for the same infusate mix; additional hours reported with additional hours therapeutic infusion code (96366); and it is okay to report multiple sequential infusion codes if multiple different drugs are given Ø Infusion must be 16-91 minutes apply the infusion time requirement Ø Remember this is a SEPARATE infusate mix 104

Question: How should an IV infusion of the same infusate that s given multiple times during 1 visit be reported? Answer: For example, calcium and magnesium are combined with D5W in an IV bag and one 20 minute infusion is given pre- chemo and one 20 minute infusion is given after chemo. This infusion would be billed as one sequential infusion, up to 1 hour (96367). The two 20- minute infusions of calcium/magnesium would be added together for a total of 40 minutes. 105

Concurrent Add- on code when multiple infusions are provided simultaneously through the same IV line, with different bags. v No code for concurrent administration of chemo drugs, but if it does happen, then the unlisted chemo admin code 96549 should be reported. v Multiple substances mixed in one bag are considered to be one infusion ( infusate mix ), not a concurrent infusion. v There is no concurrent code for hydration because it is not separately paid. v Still no separate payment for the concurrent infusion code (96368) in HOSPITALS by Medicare (ONLY) 106

Repeat: Key Times for Reporting } IV infusion of short duration is still defined as 15 minutes or less - report with an IV push injection code. } Initial or 1 st hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions but not to hydration). } Additional hours of infusion vreport add- on codes for additional hours of infusion (beyond the 1 st hour) only after more than 30 minutes have passed from the end of the previously billed hour (i.e. 91 minutes would then be an additional hour, e.g. 96415) 107

Time Documentation Per AMA Infusion time is measured when the infusate is actually running: pre and post time are not counted. It is recommended to document BOTH infusion start and stop times. Remember that a reviewer must be able to determine the actual amount of time a medication is administered from the patient chart, not just the ordered infusion time. There is no such thing as chair time ; it is infused time 108

What? NO Stop Time Documented? Can you report an infusion, injection, or nothing when the stop time is missing? v CMS has stated to some intermediaries that a short- duration infusion (i.e. less than 15 minutes) can be reported as an IV push injection. therefore, if there is no stop time, would the infusion automatically be 15 minutes or less v CMS does not have a specific rule about this at all so they could totally disallow it v Remember, if there is no stop time for hydration you cannot report anything unless more than 30 minutes is recorded v If nursing in your facility consistently omits START and/or STOP times, this should be corrected 109

Using Modifier - 59 } Modifier - 59 must be used in specific situations and you may find that you are using them more frequently than what was initially expected. vuse Modifier - 59 if two vascular access sites are started vuse Modifier - 59 if multiple encounters occur on the same date of service, e.g. patient goes home and comes back for hydration vcci edits for drug admin are being applied in full, therefore the traditional rules for modifier - 59 are in effect; no code pairs are exempt from the CCI edits 110

Code Descriptors Injection and Intravenous Infusion Chemotherapy 96523 Irrigation of implanted venous access device for drug delivery systems 96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents 96549 Unlisted chemotherapy procedure v v v v Code 96523 does not require direct physician supervision. That is CPT, not Medicare. Drug administration is still an incident to service, unless you hear otherwise. Do not report 96523 if an administration or E& M service is provided on the same day. 96545 has been deleted. For collection of blood specimen from a completely implantable venous access device, use 36592. Medicare does not pay for it with any other service, but private payers often do. 7/28/16 CPT Codes American Medical Association. All rights reserved. 111

CP, Chapter 12, Section 30.5 (F) Chemotherapy Administration (or Non- chemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same Day. For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a non- chemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005. Physicians providing a chemotherapy administration service or a non- chemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with 30.6.6 using modifier 25. The carriers pay for evaluation and management services provided on the same day as the chemotherapy administration services or a non- chemotherapy injection or infusion service if the evaluation and management service meets the requirements of section 30.6.6 even though the underlying codes do not have global periods. If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required. 112

CP, Chapter 12, Section 30.6.6 CPT Modifier - 25 - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure: Medicare requires that Current Procedural Terminology (CPT) modifier - 25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified non- physician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post- operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier - 25 is added to the E/M code on the claim. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non- physician practitioner in the patient s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim. 113

New and Old

Signatures: Review Criteria Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication. The previous language in the CMS Program Integrity Manual required a legible identifier. The CMS Transmittal 327 has added additional clarification and signature assessment requirements. Any auditor can use this rule, unless other laws or regulations supersede this rule.

SIGNATURES: CMS AUDITS If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record beyond the short delay that occurs during the transcription process and should instead use the signature attestation process. Other providers in the same group may not attest to the original author s signature. In addition, if the Medicare policy is silent on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date. All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete. If a signature is not legible or is missing, the providers should take the appropriate steps to comply with the requirement in advance to prevent delays regarding the outcome of the review. Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR).

Medical Records Salvo If it wasn t written, it wasn t done: Caveats If you can t read it, it wasn t done If you can t find it, it wasn t done If it is not filed in the record, it wasn t done. If it was not ordered, it wasn t necessary.

Coding for Drugs The Keys Know the J- code dose Know what was given Know what was wasted Make sure all units are documented in the record Know when to bill waste

Reporting Drug Dosage When dosage amount in mg is greater than amount indicated for HCPCS code - Round up to determine units Coding example calculating units HCPCS code: J0000 Drug: XYZ drug Drug narrative dosage: 2 mg Actual dose administered to patient: 5 mg Report on Medicare claim: HCPCS code: J0000 Units: three 5 mg divided by 2 mg = 2.5 units (round up to 3)

Medicare will pay for drug waste of single use items that are medically necessary and wastage appropriately documented in the record. ØLCD:Drugs and Biologicals, Non- Chemotherapeutic 4I- 81AB- R21 Øhttp://www.trailblazerhealth.com/Tools/LCDs.aspx?Doma inid=1

Billing With - JW Effective January 1, 2017, all drug claims for single dose vials (SDVs) must reflect the amount of drug wasted: Two lines one for the drug used; the other for the amount wasted with Modifier JW Exception: when the J- code unit exceeds the amount given plus wastage Wastage must be documented in the record Every effort should be made to minimize wastage

Multi- use Vials What is a Multi- dose Vial?? Multi- use vials are interchangeably acceptable to be called multi- dose vials. A multi- dose vial, is a vial of powdered medication intended for parenteral administration (injection or infusion) that contains more than one dose of medication and thus can be given to more than one patient. Multi- dose vials are labeled as such by the manufacturer; are approved by the FDA; and typically are reconstituted (mixing a dry powder with a liquid such as sterile water to allow the medication to be administered intravenously) with a diluent (a liquid that thins the concentration of the medication) containing an antimicrobial preservative to help prevent the growth of bacteria and lengthen the shelf life of the medication. The preservative has no effect on viruses and does not protect against contamination when healthcare personnel fail to follow safe injection practices.

Multi- Use Vials Did You Know... When a drug is packaged in a multi- use vial, Medicare will reimburse only for actual amount administered to patient Medicare will not reimburse for drug wastage on a multi- use vial?? So, therefore, - JW does not apply to them in January

Example Incorrect Units Hospital ABC administered 110 mg of trastuzumab to a patient and billed for 44 units of service (440 mg). Based on HCPCS description of trastuzumab, 10 mg, number of units to be reported for 10 mg is 11 Incorrect 110 mg trastuzumab Administered, Billed for 440 mg or 44 UOS Correct 110 mg trastuzumab Administered, Bill for 110 mg or 11 UOS

Things You Need Prior To Starting Patients On A New Product Package Insert NDC Oncologimab 60 mg/ vial 76075-0101- 01 Billing unit per NOC report is 1 mg, but check with payer before using Pricing information Standard Orders Payer guidelines from your biggest payers (80/20 rule) Transcription or Electronic Medical Record extraction for Prior Authorization Information on cost and dating from distributor

Billing for Miscellaneous Codes Generally there are two types of billing 1. Put all information in Box 19 or electronically in the 2400/SV101-7 loop Units may be 1 for Medicare, but will vary for private insurers Some want NDC Some want dose in 24G; some in Box 19/ 2400 2. Put NDC information in NDC loop electronically Mostly Medicaid s at this point But, there are Clearinghouses and private payers use NDCs for new and old drugs

General Billing Guidelines for J9999 & J3590/J3490: Medicare Create billing code in practice management system or Charge Description Master for new not otherwise classified drug at smallest billing unit value (example 1 mg). Post new drug code charge at a multiple of the billing unit to equal patient s dose. Remember to use modifier JW for wasted drug, where this is required by Medicare Attached to the line item drug charge, enter the following information in the 2400/SV101-7 for electronic claims or Box 19 on CMS- 1500 paper claims or 2300 loop in CMS- 1450, FL 80 of CMS 1450: Drug Name NDC Number Total dose given Total vials or amount wasted (if JW is used) Method of administration

Entry of Correct NDC Numbers Each NDC must be reported as an eleven digit number based on the 5-4- 2 principal without these dashes that we demonstrate below: 10- digit format on pkg 10- digit format by example 11- digit format 11- digit example 4-4- 2 9999-9999- 99 5-4- 2 09999-9999- 99 5-3- 2 99999-999- 99 5-4- 2 99999-0999- 99 5-4- 1 99999-9999- 9 5-4- 2 99999-9999- 09

Let s Be Careful Out There

Multiple Layers of Audits Federal Medicare Incorrectly Billed Claims Processing Errors Medical Necessity Incorrect Payment Amounts Non- covered Services Incorrectly Coded Services Duplicate Services RAC X X X X X X X MAC X X X X X X X ZPICs X X X X X CERT X X X X X MAC Billing Audits X X X X X X Office of Audit Services Audits X X X X Annual Work Plan Projects X X X X X X Large $ Items X X X

Don t feel like the roof fell in... Ø Be Prepared! 131

Audit Risk Use of modifier - 25 with too many visits, chair visits Hospital visits New versus established patients (RAC) Drug units Level 5 visits (NGS)

Audit Risk Drug Administration Two initial codes in one day with/without - 59 Use of 96368 for more than one drug in a bag Confusion about use of sequential codes as opposed to additional hours Medically unnecessary use of sequential infusions versus IV push Billing for waste in the biggest vial size Billing of fluids to transport drugs Billing of 36000 with drug administration Billing of 96523 with other services Billing 36591-36592 with other services

Responding to Audit Requests Ø Usually your first contact with the auditors will be a written request for documents. This usually comes by FAX. Ø Often you will receive additional written requests for documents and/or verbal requests for additional documents. Ø How do you respond to all of these requests? Ø Do you know what type of audit that you are responding to? Are they planning to come to your facility? Ø Have a Plan and Team put together before the audit begins! Ø Do you need a lawyer?

WHO s WHO MACs/ Carriers per their own internal screens CERT Auditors The OIG Medical Integrity Contractors ZPICs Private Insurance Companies on behalf of MA or themselves.

Preparing for Review 1. Try to figure out what they are looking for what do charts requested have in common drugs, procedures, visits 2. Get personally involved with seeing that charts are put together correctly. 3. Call the requestor, if you have questions 4. Copy ALL records involved in the request office, hospital, lab. 5. Check for legibility and continuity of charts. Find unfiled documentation, if that is an issue 6. When in doubt, send more rather than less- - - but do not send unrelated material.

Preparing for Review 6. Check for correct provider names, dates, authentication. 7. For major audits, have a physician and nurse reviewer. 8. Write addenda as necessary. 9. Send to the correct contractor. 10. Make sure documentation gets there when it is due. Send by traceable mail (Express, Fedex, etc) 11. Keep a record of records checked out, why request was made, and to whom.

Auditors are not cancer psychics! Hmmmm you counseled the patient regarding the chemo and care at home but the time of counseling is not clear Ø Medical Record Reviewers do not fill in gaps in a note or lapses in dictation. Ø If it wasn t written, it was not done not negotiable!! Ø Cutting and pasting or templates can get you in trouble Ø Documentation for each visit, treatment and procedure must stand alone: Medical Record Reviewers will NOT look back at prior notes to support a level of service. 138

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