Gastroenterology Workshop: Part 2 Compliance Issues

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Gastroenterology Workshop Part 2Compliance
Issues Endoscopy Billing

• McVey Associates, Inc
• Sponsored by
• NASPGHAN
• October 21 22
• Buena Vista Palace Resort SPA
• Orlando, FL

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Presenter

• Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS
• 204 E Locust St
• Lenzburg, IL 62255
• Fax [phone]
• E-mail askmueller_at_aol.com

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Scenario 1
Dr. Smith is a patient in our practice.
Because he refers many of his patients to our
practice, we never bill Dr. Smith, his staff, and
other members of his family anything over what
insurance pays for their services.
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Professional Courtesy (STARK II)

• Professional courtesy is defined as "the
• provision of free or discounted health care items
• or services to a physician or his or her
  immediate
• family members or office staff". Besides the
• prohibition to Medicare patients, the following
• rules apply to all other patients

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Professional Courtesy (STARK II)

• Phase II effective date July 26, 2004
• Must be offered to all physicians on the
  practices staff or in the local community
  without regard to volume or value of referrals
• May include only those services regularly offered
  by the practice

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Professional Courtesy (STARK II)

• Must be a policy written and approved by top
  practice management
• Cannot be offered for copay waivers unless the
  insurance company paying the bill is informed in
  writing
• Does not violate anti-kickback laws or claims
  submission rules and regulations.

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Scenario 2 A patient presents to a
hospital-based clinic complaining of blood
emanating from his rectum and severe abdominal
pain. As instructed, the staff hands the patient
a clipboard with a patient registration form and
asks the patient to complete the form which
includes the patients insurance information.
Only after the patient completes the form is the
patient seen by the physician.
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EMTALA
Any patient that presents to a hospital-based
clinic in a potentially emergency situation must
be given a screening examination before he/she is
questioned regarding their health insurance.
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Scenario 3 Though our practice is very careful
when it comes to billing Medicare or Medicaid for
all applicable copays, coinsurance and
deductibles, we do offer professional courtesy in
the form of bill insurance only to commercial
payors for services provided to the medical
community.
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False Claims Act
It is a violation of federal law to submit a
claim for payment for a service when the amount
billed does not represent the amount that is
actually charged.
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HIPAA
Anti-kickback and False Claims apply to all
health care benefit programs, federal or
private.
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Scenario 4 The family of our patient, who
was recently admitted to a nursing facility,
asked if we could continue to see the patient in
the nursing facility. Since we are not
accustomed to seeing patients outside our office
or hospital, and since the Medicare payment that
we would receive would not be sufficient
compensation for the travel time back and forth
to the nursing facility, we asked the family to
pay a nominal amount above the Medicare allowed
amount to cover our additional costs.
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Medicare Regulations
Unless the physician opts out of the Medicare
program, he/she can not charge more than the
Medicare allowed, for participating providers, or
the limiting charge, for non-participating
providers, even if the patient is willing to pay
more.
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Scenario 5 One of the drug reps that comes to
visit our office with samples of her products,
often will provide our staff with, pens, pads,
and other small items. Once a month she brings
lunch for the physicians and staff, often from a
gourmet restaurant. For Christmas, she brings a
pair of theater tickets for each of us.
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Anti-kickback
Anything over 300 per year in total value is
suspect.
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Scenario 6

• The Practice has hired a nurse to manage our
  inflammatory bowel clinic. On occasion the
  physician is not in the office during the clinic
  hours. The Practice bills a 99211 for the nurse
  visit under the physicians name.

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Incident To...

• The Incident to provision of Medicare allows a
  physician to bill for services provided by
  someone else assuming the following criteria are
  met
• The person providing the service is an employee
  of the group.
• The person providing the service is directly
  supervised by the billing physician.
• The service is part of a course of treatment
  prescribed by the physician.

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Scenario 7

• A practice brings on a new associate. It
  takes several months before the associate
  receives all her insurance provider numbers. In
  the meantime, services provided by the new
  associate are billed using the provider numbers
  of another physician in the group.

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False Claims Act

• Whether Medicare or any other private
  insurance carrier, a claim identifying the
  provider as one person, when in fact the person
  providing the service was someone else, is
  considered a false claim.

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Scenario 8

• A patient calls the office wanting to be
  scheduled for a screening colonoscopy. The
  physicians in this practice feel strongly that
  the patient should be seen and examined prior to
  scheduling the procedure. The patient is asked
  for the name of her primary care physician. The
  visit preceding the colonoscopy is billed as a
  Consultation.

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False Claims Act

• A Consultation in billing terminology requires
  a request from another physician for an
  evaluation of a specific problem. As the request
  was for a screening colonoscopy only, the visit
  can not be billed as a Consultation and the claim
  is a False Claim.

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Scenario 9

• A patient received a procedure during which
  biopsies were taken and sent to the laboratory.
  The results come back negative. The nurse calls
  the patient at home and leaves the following
  message on the answering machine Mrs. Jones,
  this is Dr. Smiths office. Your tests came back
  negative. Everything is normal. Call us to
  schedule an appointment for 6 months.

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HIPAA

• HIPAA precludes the practice from leaving
  patient identifiable information on a machine
  that is not secure. This practice also violates
  state confidentiality laws.

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Scenario 10

• An attending physician in a teaching hospital
  supervises a resident clinic. The attending only
  sees the patient when requested by the resident.
  The attending reviews and signs all the charts
  and bills for all the services provided by the
  residents.

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Physicians at Teaching Hospitals Guidelines

• For the service to be billable by the attending
  physician, he/she would have to see the patient
  and document his/her participation in each
  component of the service History, Examination,
  and Medical Decision Making.

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Scenario 11

• A practice receives a letter from Medicare
  requesting the medical record documentation for
  10 services. Since the documentation was minimal
  or non-existent, the physicians destroyed the
  original documentation and dictated new
  documentation for the 10 services which were sent
  to Medicare.

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Obstruction of Justice

• It is prohibited for a physician to destroy or
  alter medical record documentation without
  identifying the change and the date it was made.
  Doing so is a felony.

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Scenario 12

• The practice decided to withdraw from
  participation in a major managed care plan
  because they discovered that the out-of-network
  payment is considerably higher than the
  in-network payment. To minimize the
  out-of-pocket expenses of the patients, the
  practice waives the co-insurance.

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False Claims Act

• The amount billed to the insurance company must
  reflect the amount that the practice intends to
  collect, including the patients responsibility.
  If the practice does not intend to pursue the
  patient for their responsibility, the insurance
  company can refuse to pay the practice for the
  service.

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Scenario 13

• Because the insurance company does not pay for
  routine physical examinations, the practice gives
  the patient a statement indicating that the
  patient had symptoms, when no significant
  symptoms actually exist.

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False Claims Act

• Changing the diagnosis to make a non-covered
  service into a covered service is considered
  fraud even if the practice does not stand to
  benefit.

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Scenario 14

• Because the physician does not understand the
  billing and coding process, he relies on the
  biller to code the services. The biller uses the
  same level of service for all E/M services,
  resulting in upcoding for some and undercoding
  for others.

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False Claims Act

• The physician has responsibility for the
  accuracy all services billed under his signature.

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Scenario 18 Our office is on the campus of the
hospital. We pay a token rent and the hospital
provides the support staff. We bill place of
service, office.
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Anti-kickback, Stark II, False Claims
1. The Hospital is providing something of value
(reduced rent and staff) in exchange for
referrals. 2. The Physicians are referring to
hospital (designated health entity) where they
have a financial interest (subsidized rent and
staff). 3. The physicians are Billing place of
service, office, when the practice does not
incur all the overhead expenses.
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Compliance Check List

• HIPAA
• Sit in the waiting room to see if you can
  overhear any conversation with or about patients.
• Stand at the front desk and see if you can read
  the computer screen or view any patient
  information on the desk.
• Walk through the office to see if any patient-
  information is left in public places.

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Compliance Check List

• HIPAA Continued
• Make sure exam room and consultation room doors
  are closed when the physician of other staff
  person is talking to a patient.
• Instruct your staff never to leave test results,
  instructions, or other information that identify
  a problem or procedure on an answering machine or
  with anyone other than the patient unless the
  patient specifically agrees in writing.

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Compliance Check List

• Coding and Billing
• Unless you are a Medicare non-participating
  provider, you should have one fee schedule for
  all patients.
• Design a written discount policy for indigent
  patients and follow the policy consistently.
• Eliminate professional courtesy.

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Compliance Check List

• Coding and Billing Continued
• Bill only those services documented in the
  medical record.
• Schedule annual training sessions for physicians
  and staff.
• Train new physicians as soon as they start.
• Code all services accurately.
• Do not send duplicate claims unless the insurer
  indicates that the claim was lost.

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Compliance Check List

• Coding and Billing Continued
• Make sure all information on the claim form is
  correct, including the name of the provider, the
  procedure and diagnosis codes.
• Code the primary diagnosis with the reason for
  that specific encounter.
• Select the level of service that is medically
  appropriate for the patients condition as
  documented in the medical record.

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Compliance Check List

• Coding and Billing Continued
• Select the correct category of service as
  documented in the medical record.
• Vary the level of service according to the
  patients problem.
• Use templates to document all of the elements of
  a visit.

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Compliance Check List

• Incident to
• Get your mid-level providers their own provider
  numbers.
• New Patient Visits and Consultations should be
  billed under the person who provided the service.
• Assure that there is a physician in the office
  whenever a service is provided by a nurse,
  medical assistant, or technician.
• Bill NPP services under a physician who is in the
  office and only for established patient visits.

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Compliance Check List

• Teaching Physicians
• Bill attending services if performed entirely by
  the attending or appropriately documented when a
  resident or fellow participates in the service.
• Never bill for a procedure performed by a
  resident or fellow if the attending did not meet
  the requirements.

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Teaching Physician Documentation Requirements

• Teaching Physician must personally document
• She/he performed the service, or were physically
  present during the key or critical portions of
  the service when performed by the resident or
  fellow
• His/her participation in the management of the
  patient
• Reference the residents note

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Teaching Physician Documentation Requirements

• Examples of Unacceptable Documentation
• Agree with above
• Rounded, reviewed and agree
• Discussed with resident
• Seen and agree
• Patient seen and evaluated
• A legible countersignature alone

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Teaching Physician Documentation Requirements

• Examples of Acceptable Documentation
• I personally saw the patient with the resident
  and agree with the residents findings and plan.
• I saw and evaluated the patient. Discussed with
  resident and agree with residents findings and
  plan as documented in the residents notes.

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Teaching Physician Documentation Requirements

• Examples of Acceptable Documentation
• I personally examined and evaluated the patient,
  reviewed the residents notes and made any
  appropriate corrections. My concern for this
  patient is ..
• I saw and evaluated the patient. I reviewed the
  residents note and agree, except.

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Compliance Check List

• Stark and Anti-kickback
• Never give or accept anything of value as an
  inducement for referrals.
• Never give or accept anything of more than 50 in
  value from another health care entity.
• Any service provided to or by another health care
  provider should be paid at market value.
• Do not refer patients to any designated health
  care entity in which you have a financial
  interest.

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Compliance Check List

• General
• Write and implement a Compliance Plan.
• Designate a Compliance Officer.
• Take reports of potential violations seriously.
• Never punish an employee for reporting a
  potential compliance violation.
• Perform periodic medical record reviews.

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NO GRACE PERIOD FOR 2005 or 2006

• HIPAA gives us another major change
• Effective October 1, 2005, the 2006 ICD-9-CM
  codes are to be submitted to all carriers
• Effective January 1, 2006, the 2006 CPT-4 codes
  are to be submitted to all carriers.

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Type of Endoscopy Code Range
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Type of Endoscopy Code Range
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Esophagoscopy, Upper GI Endoscopy, and
Enteroscopy

• Esophagoscopy limited to study of the
  esophagus.
• Esophagogastroduodenoscopy (EGD) - including
  study of the esophagus, stomach, and either the
  duodenum and/or jejunum
• Enteroscopy (PUSH)- Past the second portion of
  the duodenum, into the jejunum and up to and
  including the ileum.

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Flexible Fiberoptic Sigmoidoscopy

• Intent to only visualize the rectum, anus,
  sigmoid, descending and can include the splenic
  flexure.
• When a colonoscopy is discontinued prior to the
  splenic flexure, it is still to be billed as a
  discontinued colonoscopy when the initial intent
  was colonoscopy.
• Most ASCs and outpatient departments do not get
  financial payment for FFS since it is considered
  an office based procedure.

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Colonoscopy

• The scope goes beyond the splenic flexure
• If done on a patient with a good majority of
  colon removed, it can still be billed as
  colonoscopy with reduced service modifier 52
• If done on a patient with j pouch, Hartmanns
  pouch, etc., bill the pouchoscopy codes.(44385)

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Endoscopic Biopsy

• This code should be reported only one time
  regardless of the number of biopsies performed.
  If multiple biopsies are performed in different
  areas of the upper GI tract, the most extensive
  biopsy would be reported.

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Endoscopic Biopsy

• If one lesion is biopsied and a separate lesion
  (from another site in the intestine) is removed
  during the same session by means of a separate
  technique other than the biopsy, it would be
  appropriate to report a code for the biopsy of
  one lesion and an additional code for the removal
  of the separate lesion.

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Endoscopic Biopsy

• The use of 59 modifier is essential when biopsy
  for one lesion and removal of a separate lesion
  with a different technique. The modifier is
  added to the biopsy lesion.
• If a Clo-test (test for Helicobacter pylori), is
  performed, this is correctly billed as a biopsy.

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Endoscopic Hot Biopsy Removal

• The number of lesions removed by hot biopsy are
  not reported separately
• Different techniques at different sites within
  the intestine can be reported with the
  appropriate modifier.
• Anoscopy includes hot biopsy and snare in the
  description

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Endoscopic Snare Removal

• The number of lesions removed by snare are not
  reported separately
• Different techniques at different sites within
  the intestine can be reported with the
  appropriate modifier.
• Can be cold or hot snare

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Endoscopic Ablation of Lesion

• This code is reported only one time for any
  number of lesions removed by the above
  techniques.
• Can be used on sessile polyps, AVMs
  (arteriovenous malformations), or other
  suspicious areas within the GI tract.
• Can be accomplished by APC (argon plasma
  coagulation) among some of the methods.

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Endoscopic Lesion Removal

• The appropriate code for lesion removal and/or
  ablation are selected based on techniques of
  removal.
• They are to be reported only once per operative
  session regardless of the number of lesions
  treated using that treatment method.
• Check the operative report carefully to verify
  the technique used to remove the lesion(s).

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Endoscopic Lesion Removal

• Multiple lesions may be removed using different
  techniques, i.e., snare, hot biopsy, ablation.
  If different techniques are used in separate
  areas of the GI tract, choose the codes that
  describe each technique used.
• The second, third, fourth, etc., techniques are
  listed with a 59 modifier to indicate a separate
  site within the intestine when the component code
  is bundled into the most comprehensive code.

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Endoscopic Retrograde Cholangiopancreatog
raphy (ERCP)

• The common bile duct is cannulated, dye injected,
  and the biliary tree is visualized.
• The collection of specimens by brushing or
  washing is included in reporting this code.
• Multiple techniques are reported without the 59
  modifier. Exception Insertion of more than one
  tube or stent can be reported necessitating the
  59 modifier when applied to 43268 and 43269.

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Tips for Endoscopy Reports

• Make sure that there is a pre-operative and
  post-operative diagnosis. Even if the endoscopy
  is negative, go back to the original reason for
  the procedure as the diagnosis for the endoscopy.
• Be specific as to how the biopsy/polypectomy was
  performed i.e., snare, hot biopsy forceps,
  ablation, etc. The phrase multiple polypectomies
  does not give us enough information to submit a
  claim.

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Tips for Endoscopy Reports

• LOCATION! LOCATION! LOCATION! In order to get
  paid for different techniques in different sites
  within the intestine, the location of the lesion
  is essential in order to apply the appropriate
  modifier -59.
• If a Clo-test was done, this is billed as a
  biopsy. Make sure that this is mentioned in the
  report. Too often, this is only contained in
  pathology

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Tips for Endoscopy Reports

• Wait for pathology report before assigning
  diagnosis code. Neoplasm uncertain behavior does
  not mean that the area looks suspicious, it means
  that there is atypia or dysplasia. Suspect
  Crohns disease does not mean you have Crohns
  disease.
• MOST IMPORTANT!!!! The procedure note has to be
  legible. The solution DICTATE YOUR NOTE!!!!

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Tips for Endoscopy Reports

• If 25 biopsies were taken during the session,
  please make sure to also add how much additional
  time this took you to do. The same applies to
  multiple polypectomies by snare or hot biopsy,
  etc. The book states biopsy(s), polypectomy(s),
  so this means you cant bill more than one code.
  If your documentation states how much extra time
  and how much more difficult this procedure was, a
  -22 modifier can be added to the claim.