Level 2 vs. Level 3 H&P Coding Comparison.

This lecture will assist physicians and other non-physician practitioners (NPPs) determine if their initial hospital admission note documentation meets criteria for a level 2 (mid level H&P) or a level 3 (high level H&P) evaluation and management (E/M) code.  Recovery Audit Contractors will likely continue to target high level initial hospital encounters for improper payments.  Physicians and other NPPs must continue to pursue documentation education to prevent accusations of over billing and to prevent under billing for work provided.  I am an internal medicine physician with over 10 years experience as a clinical hospitalist.  Based on my decade of experience and exhaustive review of E/M coding criteria, I believe most level 2 H&P hospital admissions would qualify for a level 3 H&P if practitioners understood how to document  work already being provided.  The link above provides free access to dozens of billing and coding lectures I have written to help others quickly decipher the complex rules used to determine the correct CPT® code for most inpatient and outpatient hospital and clinic encounters. 

CPT® DEFINITIONS


The American Medical Association's 2014 Standard Edition CPT® provides definitions of all E/M services.  This valuable resource is available through Amazon by clicking on the image to the right and below.   I have previously discussed level two initial inpatient and observation hospital admission (CPT® 99222 and 99219) and level three initial inpatient and observation hospital  admission (CPT® 99223 and 99220) codes in detail and I recommend all readers thoroughly review these lectures at their convenience.

To simplify understanding of the differences between a level 2 and a level 3 hospital H&P, I will treat the criteria for a level two initial inpatient hospital admission (CPT® 99222) the same as a level two initial observation hospital admission (CPT® 99219) and I will treat the criteria for a level three initial inpatient hospital admission (CPT® 99223) the same as a level three initial observation hospital admission (CPT® 99220).  In both cases, their criteria are equivalent for all intents and purposes.

     LEVEL 2  CRITERIA

A level 2 initial hospital admission note requires documentation of a comprehensive history, a comprehensive examination and medical decision making of moderate complexity.  Presenting problem(s) are usually of moderate severity (50 minutes).

     LEVEL 3  CRITERIA

A level 3 initial hospital admission note requires documentation of a comprehensive history, a comprehensive examination and medical decision making of high complexity.  Presenting problems are usually of high severity (70 minutes).
Supporting documentation required for a level two note is identical to a level three note for history and examination.  Shown in red, the only difference is the complexity of the medical decision making that documentation supports.  If an initial hospital admission note does not have documentation to support a comprehensive history and examination, the highest level of service that can be billed is a level 1 H&P (99221 or 99218).

               TIME 

The CPT® definitions also provide guidance on expected time for the encounter.  However, time can only be used in conjunction with the rules of counseling and coordination of care.  Time based billing has been discussed elsewhere on The Happy Hospitalist and is not relevant to this discussion.

               NATURE OF THE PRESENTING PROBLEM

The CPT® definitions also provide guidance on the nature of the presenting problem.  How does one audit a note for moderate severity or high severity?  The CPT® handbook attempts to define moderate severity and high severity.  Unfortunately, they chose to use the words moderate and high within their own definition.  This makes standardized interpretation difficult.
Moderate severity:  A problem where the risk of morbidity without treatment is moderate, there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional  impairment. 
High severity:  A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
These vague CPT® definitions are difficult to interpret in clinical practice.   How does one audit moderate or high risk based on this CPT® guidance?  One cannot.  That's why these elements of the CPT® definition are rarely enforced in audit scenarios without using alternative tools (discussed below) to define the level of risk and complexity.   What may be moderate or high to one patient, doctor or specialty may be moderate or high to another.  One  could argue all patients that need to be admitted to the hospital risk a high probability of morbidity or mortality without treatment.  That's why they are in the hospital.

     CLINICAL EXAMPLES 


Appendix C of the CPT® manual provides pages and pages of clinical examples for a level 2 and level 3 hospital admission.  These examples are a tragic example of failure to appreciate the complexities of patient care.  These one and two sentence scenarios cannot tell the whole picture nor do they represent the reality and complexity of patient encounters in real life.   I provide two Internal Medicine examples below from the CPT® handbook.

          Level 2 H&P (99222)
Initial hospital visit for a 61-year-old male with history of previous myocardial infarction, who now complains of chest pain.
CPT® provides this scenario as an appropriate level 2 admission.  I disagree.  Consider the scenario where an emergency department physician recommends admission to the hospital for evaluation and management of this patient with chest pain and a known prior history of myocardial infarction.  If the patient declined admission and left the emergency department against medical advice, any reasonable discharging physician would have an informed consent discussion with the patient detailing the high risk of death or disability.   By default, that would make this presenting problem of high severity and in direct conflict with the  assumption that this presenting problem was of moderate severity.  However, a cardiologist, after reviewing the data in the emergency department may have a different perspective and believe safe discharge from the emergency department is acceptable with low risk for complications.  There in lies the dilemma.    Defining moderate and high severity is open to great interpretation and cannot be reliably audited for payment purposes.  Therefor, it should not be audited without more definitive criteria.

Regardless of the inability to audit vague terminology such as moderate or high, these CPT® clinical examples are not representative of real life patients.  Most patients do not present with single diseases.  Their complexity rises exponentially with other comorbid conditions.  I do not place faith on these CPT® examples for providing appropriate coding guidance.   This is why alternative methods have been developed to define moderate and high complexity and risk in audit situations. Here is a CPT® example of a level 3 inpatient hospital admission.

          Level 3 H&P (99223)
Initial hospital visit for a 70-year-old male with cutaneous T-cell lymphoma who has developed fever and lymphadenopathy.
I agree.  However, I also believe the vast majority of all hospital admissions are complex enough to warrant the highest level of service.  That's why they are in the hospital.    In addition, based on risk defining criteria that has been developed, thorough documentation of work provided will often provide confirmation of high complexity medical decision making.
   

DIFFERENCE BETWEEN A LEVEL 2 AND LEVEL 3 H&P


The audit components of a level 2 and a level 3  inpatient or observation hospital admission are exactly the same with the exception of the medical decision making (MDM) component.   While CPT® definitions include reference to the severity of the presenting problem, I've established above how determining the level of service based on that criteria is impossible.  Official CPT® examples do not represent the realities of clinical medicine.  So how is the correct level of service determined?  Based on the CPT® definitions, audit decisions are decided with a detailed analysis of history, examination and medical decision making documentation.

As discussed above, the history documentation requirements and the examination documentation requirements are identical for a level 2 and level 3 initial hospital admission note.  An auditor, who may have no medical training, cannot reliably categorize medical decision making, risk or severity of a presenting problem as moderate or high without checkbox criteria to assist in their efforts.  Even Medicare's own Evaluation and Management Services Guide provides only vague instructions on determining the level of complexity for MDM.   Enter the Marshfield Audit Clinic Tool and point system (reviewed below)  that was developed to provide additional guidance and support.  The only audit tool difference between a level 2 and a level 3 initial hospital admission is the medical decision making component.  For a level 2 hospital H&P, documentation should support medical decision making of moderate complexity.   For a level 3 hospital H&P, documentation should support medical decision making of  high complexity.  This is where the Marshfield Clinic Audit Tool provides guidance.

MEDICAL DECISION MAKING (MDM)


      MARSHFIELD CLINIC AUDIT TOOL


Where did the Marshfield Clinic point system E/M tool come from? It was developed in the early 1990s at a 600 physician multi-site, multi-specialty, mostly office-based practice in Wisconsin where Medicare's 1995 EM guidelines were beta tested. This medical decision making point system audit tool was developed by clinic staff and their local Medicare carrier. These scoring tools never made it into the official guidelines, but are accepted as a standard audit tool by most carriers today.  I have created an E/M pocket guide as a rapid bedside decision tool that incorporates their guidance into clinical decisions.  Details of this bedside reference can be found at the link provided just above.  These cards are available for purchase.  All proceeds are donated to charity.


LINK TO E/M POCKET REFERENCE POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



Click image for high def view


     CMS GUIDANCE ON MEDICAL DECISION MAKING


Why do many Medicare carriers use the Marshfield Clinic Audit Tool to determine the correct level of service provided?  Medicare's description of medical decision making in the Evaluation and Management Services Guide (page 33) contains vague language that cannot be reliably reproduced in clinical practice.  Here is a screen shot of the E/M Services Guide discussing medical decision making criteria.

Medicare E/M Services Guideline Medical Decision Making

How can a practitioner or auditor reliably determine when the number of diagnoses are multiple or extensive?  How can a practitioner or auditor reliably determine when the  amount and complexity of data is moderate or extensive?  They can't.  Ironically, determining the correct level of medical decision making complexity is complex.   Just as the CPT® definitions use vague language in defining their codes, the E/M Services Guide also uses the same difficult language to guide physicians and other NPPs.  This is a tragedy.  This is why The Marshfield Clinic Audit Tool for MDM was developed and used by auditors and practitioners to stay compliant.  Pages 33-37 of the E/M Services Guide provides the basis for the Marshfield Clinic Audit Tool point system shown above on The Happy Hospitalist's bedside pocket E/M reference card.  It provides quick access to documentation elements converted into Marshfield Clinic Audit Tool points. It may also help providers remember to document work provided but rarely described in the chart in order to get credit for documentation elements in an audit situation.    For example, in the number of diagnoses or management options component of medical decision making,  four points is given for a new problem with more workup planned when using the Marshfield Clinic Audit Tool.  This is based on Medicare's E/M Services Guide (page 34) description of diagnosis complexity here.
The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. 
This same point system applies to the amount and/or complexity of data to be reviewed.  For example, one point is given for review or ordering of  laboratory services in the Marshfield Clinic Audit Tool.  This  decision is based on Medicare's E/M Services Guide (page 35) description of amount and/or complexity of data to be reviewed.
If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented.
Medicare does provide decent guidance on risk of complications and/or morbidity or mortality with their risk table (shown below).  However, some elements within this table contain vague language that can be open to interpretation and require  physicians and other NPPs to document their thought processes aggressively to avoid accusations of  incorrect billing when they believe high risk to the patient is present.  Drug therapy requiring intensive monitoring is one such element.  I have provided a detailed review of that component here.

      SIDE-BY-SIDE MDM CRITERIA COMPARISON


If you feel lost in this discussion, now is the time to place close attention.   When combined with history and examination documentation, the MDM makes up the final necessary component  for determining the correct CPT® code.  Remember, the history and examination documentation required for a level 2 and level 3 hospital H&P admission are identical.  Both require the highest level of service.  For history, documentation must include at least four HPI elements or the status of three relevant chronic medical conditions, 10 or more review of systems and at least one element each from past history, family history and social history.  For examination, documentation generally requires at least 2 bullets each from 9 organ systems, although I recommend readers review different examination documentation options available at the 99222 and 99223 links near the top of this lecture.

The only documentation difference between level 2 and a level 3 hospital H&P admission is in the medical decision making component.  I will try my best to tie it all together and show you just how similar a level 2 and level 3 admit are in their medical decision making elements.  Using Medicare's E/M Services Guide as a reference, I have incorporated the Marshfield Clinic point system as a side-by-side reference below.

Within the diagnosis and data elements of MDM,  points are provided for defined elements of documentation found during a chart audit.  For example, one point is allowed for a self limiting or minor problem in the diagnosis section of MDM while one point may be given for evidence the provider requested prior records.   This is the basis of the point system under the Marshfield Clinic Audit Tool that is used by most Medicare carriers.

Medical Decision Making Point System

While this point system is not officially part of Medicare's E/M Services Guide, the risk table is.  The risk table is available on page 20 or 37 of the Evaluation and Management Services Guide.  I have provided a screen shot here for quick reference.  The highest element anywhere on the risk table determines the highest overall level of risk on the risk table.  For example, a patient with an abrupt change in neurological status meets criteria for high risk on the risk table regardless of any other data points on the table.

Risk Table E/M CMS

To determine the overall level of MDM complexity, the highest two out of three elements from diagnoses, data and risk determine the overall level of MDM.  In other words, the highest level of documentation for data and diagnosis, data and risk or diagnosis and risk will determine the overall level of MDM.  Below are the minimum MDM criteria for a level 2 and level 3 initial hospital admission.  For example a patient who's documentation supports 3 diagnosis points, 1 data point and moderate risk would qualify for level 2 MDM. A patient who's documentation supports 2 diagnosis points, 4 data points and high risk would qualify for level 3 MDM.  A patient who's documentation supports 2 diagnosis points, 2 data points and high risk would not qualify for either level 2 or level 3 MDM for an initial hospital admission.

     LEVEL 2 MDM (highest 2 out of 3 determines overall level of MDM)

DIAGNOSIS:  3 points
DATA:  3 points
RISK TABLE:  moderate

     LEVEL 3 MDM (highest 2 out of 3 determines overall level of MDM)

DIAGNOSIS:  4 points
DATA:  4 points
RISK TABLE:  high

 

LEVEL 2 PERMUTATIONS


Here are all eleven potential documentation permutations for medical decision making of a level 2 hospital H&P admission.  Remember, the two out three highest levels of documentation in diagnosis, data and risk will determine the overall level of MDM.   This same exercise can be done to determine a level 3 hospital H&P admission as well.

Remember to always consider medical necessity.  For example, ordering a stress test to increase the complexity of medical decision making on a chief complaint of big toe pain may raise some red flags if the chart undergoes an audit.  I believe if you're anywhere in the ball park of practicing standard of care, justifying medical necessity will rarely be a determining factor in having to support your level of care based.

Level 2 hospital medical decision making option
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example
Level 2 hospital medical decision making example

A level 2 hospital admit E/M service could often meet documentation audit criteria for a  level 3 hospital admit if providers documented work already being provided but not described.   Some coders may say high risk must be present to meet criteria for a level 3 admit.  These coders are not following the rules provided by Medicare's Evaluation and Management Services Guide.  In reference to diagnoses, data and risk, page 33 of the E/M Services Guide says:
To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
I again direct the provider and their coders to the E/M Services Guide as their reference point.  The Marshfield Clinic Audit Tool was developed because of the vague language and difficulty in interpreting rules in Medicare's E/M Services Guide.  High complexity medical decision making can be met based on diagnoses and data elements.   As I have said before, make sure your workup is consistent with standard of care and medical necessity should never be an issue.

WHERE CAN I GET A COPY OF THE POINT SYSTEM?


Many examples of the Marshfield Clinic point system are available on the internet.  Page two of this Codeapedia reference provides a detailed description of the point system.  This point system  is the basis for the bedside E/M reference card provided by The Happy Hospitalist pictured above and  linked here again for easy reference.

MANY LEVEL 2s ARE PROBABLY LEVEL 3s


Practitioners who know how to accurately document their work are probably providing high complexity medical decision making in greater than 95% of their hospital admissions when they understand the elements of the risk table and are educated about the elements of the Marshfield Clinic Audit Tool point system.  Remember, a level 2 hospital admission has the same history and and examination requirements as a level 3 hospital admission.  All patients who are sick enough to be admitted or observed in a hospital setting should meet medical necessity for the highest level of history and examination.  Medical necessity should never be questioned in these patients

In reality, many physicians and other NPPs are scared to bill too many level 3 admit notes for fear of getting audited.  No fear should exist if documentation supports level 3  work already being provided.  If all providers would document work they are already providing and billed appropriately, level 3 hospital admission distribution would rise dramatically and physician outliers, who are coding correctly, would disappear.  Practitioners  worried about getting audited as an outlier should continue to document work they are already providing and to bill correctly, regardless of their status as an outlier.  Being an outlier is not fraudulent when documentation supports correct coding decisions.   It's quite possible that most physicians who aren't billing mostly level 3 hospital admissions are the outliers because they either don't document work they are already providing, are not providing work that is medically necessary or are intentionally under billing for fear of an audit.

RVU COMPARISON


Most E/M services are given a relative value unit (RVU) value by CMS.  I have previously discussed RVUs.  The most updated table of RVU values can be found here.  The difference in relative value units assigned to a level 2 vs. a level 3 H&P hospital admission are significant.  For practitioners who's compensation may be determined by productivity, coding accurately for work already being provided can boost payments significantly.  What are the RVU values for a level 2 and level 3 hospital admission?  For Medicare patients in 2014, one RVU is worth $35.8228.

     LEVEL 2
  • Observation (99219)  -  work RVU 2.60; total RVU 3.80
  • Inpatient (99222)  -  work RVU2.61; total RVU 3.87
     LEVEL 3
  • Observation (99220)  -  work RVU 3.56; total RVU 5.20
  • Inpatient (99223)  -  work RVU 3.86; total RVU 5.70
A level 3 hospital H&P admission is valued 50% higher than a level 2 hospital H&P admission based on total RVU and nearly 48% higher based on work RVU.  This difference is significant.

DISTRIBUTION OF LEVEL 2 vs. LEVEL 3 HOSPITAL ADMISSIONS


What is the distribution of level 2  and level 3 hospital admissions?  This can vary depending on specialty.  SHM/MGMA data from 2012 suggested  CPT® codes 99222 and 99223 were utilized 29% and 66% of the time respectively with CPT® 99221 used just 2% of the time. Other Medicare distribution data is available at the CPT® 99222 and CPT® 99223 articles linked near the top of this lecture.  These distribution numbers confirm similarity with SHM/MGMA data.

PAYMENT COMPARISON


Payments will vary based on geographical location.  Providers in New York would generally get paid more than providers in Kansas.  For example, in some localities, a level 2 hospital admission pays around $130 and a level 3 hospital admission pays around $190, a nearly 50% increase.  Failure to document work already being provided can be expensive.  Using distribution data, here are a few brief calculations assuming a hospitalist provides 600 Medicare admissions in a year.   Using SHM/MGMA data (66% level 3 and 29% level 2),  payment for these admissions would be (396 x $190) + (174 x $130) = $75, 240.  This does not include the 5% utilization of 99221 admissions.

What if providers had 95% level 3 admissions and 5% level 1 admissions?  That would provide 570 level three admissions worth $190 each.  Level 3 admissions would collect $108,300.  This is about $33,000 more than the SHM/MGMA distribution would suggest, or a 44% increase in payments.  This does not take into account alternative payer mix contributions. Remember, level 2 hospital admission documentation is different from level 3 documentation only in the medical decision making.  Knowing how to document work already being provided is valuable in any practice.

RAC AUDITORS


Medicare may be targeting inappropriate payments to providers for hospital admissions.  A practitioner's best defense against fraud accusations is to document thoroughly for work provided and to practice standard of care.  Despite being an outlier,  accurate stand alone documentation of medically necessary care should always support any coding distribution that results.   I have thoroughly reviewed Medicare's Evaluation and Management Services Guide and can confirm that fear of an audit is not an element that should be used to guide coding decisions.



St Patrick's Day Nursing Humor: Saint Potty's Day Celebration!

(HNN) While March 17th is a Saint Patrick's Day celebration for the Irish,  the beer lovers and the color green, it is also a day of excitement for nurses everywhere.  You see, March 17th is also known as Saint Potty's Day.  That's not a typo folks.  Saint Potty's Day is the glorious day of bladder salvation for hard working nurses all across this great world of ours.  While St. Patrick's Day marks the arrival of Christianity in Ireland, St. Potty's Day provides a once a year opportunity for nurses to enjoy at least one scheduled pee break in a 12 hour shift.

According to legend, Saint Potty was a 14th century recluse with post obstructive uropathy.  Many theologians believe Saint Potty had a rare form of early onset prostrate hypertrophy.  Saint Potty rarely left his home for fear of urinating all over himself.  Back in the 15th century, any man or woman caught peeing on themselves was forced to bear a yellow tattoo on their genitalia that said Out Of Order.  As any woman who has ever read Harrision's Principles of Internal Medicine knows,  an Out Of Order tattoo on the male genitals is a red flag symptom and any woman hoping for a long and prosperous relationship had best go on their merry way.

Once the bladder problems struck, Saint Potty never left his mother's home.  Then came tragedy.  At the age of 58, Saint Potty's mother died suddenly of old age.    This left Saint Potty lonely and in search of companionship.   March 17th happened to be the 420th annual Scent of a Women Festival.  It was a joyous occasion that, for centuries, provided women an opportunity to find their pheromonic relationship for life.  One can understand quickly why the smell of pee is not compatible with this meet and greet event.  Move over Juan Pablo.  Before his bladder incontinence struck him at the ripe young age of 17, Saint Potty was the Festival's favorite bachelor ten years running.  

After 20 years of living in his mother's basement and one week after his mother's death,  March 17th, 1469 marked the day of tragedy that forever changed Saint Potty's life and the nurses of this world over 500 years later.   Saint Potty jimmy-rigged a crude version of today's Foley catheter in hopes of hiding his incontinence.    He strapped a leg bag under his sheep skins and danced away the night at the Scent of a Women Festival.  He had the pick of the litter that night.  Every woman screamed "IT'S POTTY TIME" at the top of their lungs.  That is, until his bag broke and his pee pee went splat all over the dance floor.  Saint Potty was taken immediately to Big John's tattoo parlor and died the following week.

Fast forward to 1979.  Nursling Janey Jo Johnson was writing one of her biweekly research papers titled What's The Longest A Nurse Has Ever Gone Without Peeing? when she came upon the legend of Saint Potty.  She realized most nurses where just like him.   What started on March 17th, 1979 as one small nursing college's celebration of  scheduled pee breaks has turned into the largest nurse holiday in the world.   Most busy hospital nurses have at some point or another gone their entire 12 hour shift without peeing.  Saint Potty's Day is a world wide effort to provide all hospital nurses at least one mandatory three minute pee break during a twelve hour shift.  One pee-r reviewed nursing journal titled Nursing Journal Of Low Urine Output questioned the merits of such a policy.  They are now out of business.  

Twenty-five years later, Janey Jo Johnson, RN, MSN, M&M and PRN, now a night nurse at a top 100 hospital according to Newsweek says she is proud about what she has accomplished.  "Newsweek just named us the best hospital in the country for nurses to work at.  I think that has a lot to do with our mandatory two pee breaks an hour we all enjoy.  In fact,  I've never had a UTI despite being treated for gonorrhea and syphilis three times over my illustrious 25 year career in the trenches.  For us, every day is Saint Potty's Day."

Now, please enjoy these original crude medical ecards from The Happy Hospitalist Pinterest site that contains hundreds of one-liners for your professional enjoyment.

"Saint Potty's Day.  Because a scheduled bathroom break is worth celebrating."

Saint Potty's Day.  Because a scheduled bathroom break is worth celebrating nurse ecard humor photo Medical Humor Store Banner


"I got to pee three times today.  Said no nurse ever."

I got to pee three times today said no nurse ever ecard humor photo. Medical Humor Store Banner


This site is for entertainment purposes only and contains humor that may only be understood by some healthcare professionals.  Read at your own risk.



Hospital Quality Measures: Value Based Purchasing 2.0 (The Funny Version).

For years, hospital quality measures have been tracked by private and government insurance programs to try and improve the healthcare services received by their beneficiaries.  The most recent example is the Value-Based Purchasing Program (VBP) initiative by The Centers For Medicare & Medicaid Services (CMS).  How does CMS describe VBP?
"Under the Program, CMS will make value-based incentive payments to acute care hospitals, based either on how well the hospitals perform on certain quality measures or how much the hospitals' performance improves on certain quality measures from their performance during a baseline period. The higher a hospital's performance or improvement during the performance period for a fiscal year, the higher the hospital's value-based incentive payment for the fiscal year would be."
This complex program has many different elements that require hospitals and doctors to excel against their peers or face penalties and payment cuts. What are some hospital quality measures  being tracked under VBP?  There are Process of Care measures and  HCAHPS patient satisfaction surveys.    There are 30-Day Outcome Mortality measures and Patient Safety Indicators.  There are  the tracking of Healthcare Associated Infections (HAI) and hospital readmissions.  There's even efficiency measures that track spending per beneficiary.

Other programs track 30 day this and 90 day that.  There are DRGs, MS-DRGs, comorbid conditions (CC) and major complicating or comorbid conditions (MCC).  There is  PQRS for physicians and ICD-10 and CPT and E/M and Oh, Lordy, when does this madness end?

You'd think by now we would have enough hospital quality measures to track everything, right?  Think again.  The Happy Hospitalist has learned VBP Version 2.0 will include the following A-Z list of new and clinically relevant quality measures that will help computer algorithms take data mining to the next level in an effort to risk stratify hospitals, patients and doctors.  This newest Medicare effort is like VBP on steroids.  In line with all previous Medicare efforts to reduce costs by simply stopping payment to doctors and hospitals, success with VBP 2.0 will be difficult.  Happy Hospitalist sources deep inside CMS have confirmed failure by hospitals to score in the top 0.01% of every single hospital quality measure listed below will result in an automatic assumption of crappy care and a return of 99% of all payments made for the prior fiscal year.   Medicare says VBP Version 2.0 succeeds in their unstated but obvious goal of simply not paying for care anymore.

Frank, a retired physician turned top CMS data entry technician, who became a master typist when physician order entry went live at his hospital last year, says his hommies in control of the CMS checkbook hope to have Medicare costs down to about $50 a year by 2017.  "Because, frankly, we don't even have fifty bucks to pay you guys anymore", he said.

So here you are folks.  I present to you the newest collection of hospital quality measures being tracked by CMS in an effort to eliminate hospital and doctor payments for good.  If you don't yet have software programs in place to track all this data, you can purchase it for a ton of money from the AMA.  They are currently providing a 3% multiple policy discount when purchased in combination with disability insurance, life insurance, Pass Your ABIM Test insurance and You Picked The Wrong CPT® Code And Now You're Screwed insurance.

CMS is interested in your opinion and will have 14 public periods of comment to hash out the details.  If you'd like to leave any of your own suggestions for new hospital quality measures under VBP 2.0, leave a comment here or on The Happy Hospitalist Facebook Page and CMS will give your opinion thoughtful consideration.

A

  • Acting Like An Asshole-to-Anesthesiologist Consult time
  • Alcohol-to-Afib time
  • Alzheimer's Agitation-to-Angry Family time
  • AMA-to-Angry Letter time
  • Ambulance-to-Ambulate time
  • Anxiety-to-Ativan time
  • Attitude-to-Ativan time

B

  • Bad Breath-to-Brushing time
  • Bad-Heart-to-Bacon time
  • Barefoot-to-Banana Bag ratio
  • Bedridden-so-Bring to the ER time
  • Belligerent-to-B52 time
  • Beta Blocker-to-Bradycardia time
  • Bilateral Cellulitis-to-Been There For Years ratio
  • Biting-to-Benzo time
  • Blood Loss-to-BS ratio (a Surgical Care Improvement Project (SCIP))

C

  • Call Light-to-Crackers time
  • Call Light-to-Code Blue time
  • Chatty-to-Charting ratio
  • Clean Catch-to-Clean Catch ratio
  • Cold Sore-to-Consult Hospitalist time
  • Colon Cancer-to-Colostomy time
  • Combative-to-Clonazepam time
  • Common Sense-to-Complete BS time
  • Complaint-to-Call the Hospitalist time
  • Constipation-to-Colace time
  • Crappy Day-to-Call Light Fatigue ratio
  • Crazy-to-Clonazepam time
  • Critical Care-to-Coroner time
  • Cyanosis to-CPAP time

D

  • Debilitated-to-Depends time
  • Delirium-to-Discharge time
  • Dementia-to-DNR time
  • Demerol-to-Discharge time
  • Dialysis-to-Denny's Discharge time
  • Diarrhea-to-Distressed Nurse time
  • Dilaudid-to-Dessert time
  • Dilaudid-to-Doughnut time
  • Distress-to-Dilaudid time
  • Distress-to-Doughnut time
  • DNR-to-Don't Be Agressive But CPR Is OK ratio
  • DJD-to-Disability Request time
  • Door-to-Dilaudid time
  • Drug-to-Doughnut time
  • Drug Rash-to-Dermatology Consult time
  • Drunk-to-Discharge time

E

  • Ear Ache-to-ER time
  • Emaciated Elderly In the ER rate
  • ER-to-Empathy ratio
  • Ethanol-to-Entertainment time
  • Extubation-to-Exiting ICU time

F

  • Faking It-to-Full Workup ratio
  • Fall-to-Freakout time
  • Fentanyl-to-French Fries time
  • Fever-to-Full Workup ratio
  • Fibromyalgia-to-FMLA Request time
  • Fibromyalgia-to-Funny Allergies ratio
  • Frailty-to-Foley time
  • Frequent Flyer-to-Full Of It ratio
  • Full Code-to-Frailty ratio

G

  • Gangrene-to-Guillotine time
  • Gastric Bypass-to-Gimme Seconds time
  • Giving It Up-to-Gonorrhea time
  • Going Off Call-to-Go To The ER ratio
  • GOMER-to-Getting a Ride Home time

H

  • Haldol-to-Happy Nurse ratio
  • Haldol-to-Hope This Works time
  • Hot Meal In the ER-to-Hotel Discharge Time
  • Head Trauma-to-Haldol time
  • Healthy-to-Hospital Acquired Half Dead time
  • Hip Fracture-to-Heaven time
  • Histrionic-to-Haldol time
  • Homeless-to-Hypothermia ratio
  • Half Dead-to-Hotel Discharge rate
  • Hospitalist Consult-to-Hospice time
  • Hyperglycemia-to-Humalog time
  • Hyperventilation-to-Haldol time

I

  • Impatience-to-iPhone ratio
  • Intoxication-to-Intubation time
  • Irritation-to-ICU Transfer time
  • Irritation-to-Intubation time
  • IV-to-Infiltration time

J

  • Jailed-to-Jacked-Up-In-The-ER time
  • Jelly Doughnut At Nurses Station-to-Joint Commission Arrival time 
  • Jim Beam-to-Jaundice time
  • Joblessness-to-Just Fill Out My Disability Papers time
  • Joint Pain-to-Job Note Request time
  • Junkie-to-Jugular Line ratio

K

  • Ketosis-to-Kayexalate time
  • Kegger-to-Ketosis time
  • Kleenex-to-Klonipin time 
  • Knucklehead-to-Knife Injury ratio

L

  • Lactulose-to-Look Out Below time
  • Leg Edema-to-Lasix time
  • Leaving AMA before Lunch percentage
  • Leopard Tights Leaving AMA percentage
  • Lethargic-to-Lipstick time
  • Loculated-to-Levaquin time
  • Lipping Off-to-Lorazepam time
  • LOL Leaving AMA-to-LMAO ratio
  • Lung Cancer Diagnosis-to-Lighting Up time

M

  • Medicaid-to-Manicure ratio
  • Melena-to-Misty Autumn Sunrise Spray time
  • Melena-to-Morgue time
  • Migraine-to-MRI time
  • Migraine-to-Morphine time
  • Morphine-to-Manwich time

N

  • Narcotics-to-Narcan time
  • Narcotics-to-Nausea time
  • Narcotics-to-Needs Admitting time
  • Nasty-to-Nystatin time
  • Nausea-to-Nasogastric Tube time
  • Norco-to-Naked time
  • Nothing Is Still Wrong-to-No Need To Go To The ER Again time

O

  • Out Of Control-to-Olanzapine time
  • Overdose-to-OMG Really? time

P

  • Pain In My Ass-to-PCA time
  • PEG Tube-to-Palliative Care time
  • Pen Pal-to-Four Point Restraint time
  • Percocet-to-Perfect Press Ganeys ratio
  • Percocet-to-Pork Sandwich time
  • Phenergan-to-Feel Good time
  • Psychosis-to-Sitter time
  • Polypharmacy-to-Palliative Care time

Q

  • Questionable-to-Quality ratio

R

  • Respiratory Rate-to-Record 20 ratio
  • Rest Home-to-Resuscitate ratio
  • Restlessness-to-Restraints time

S

  • Sedation-to-Shaving It Off time
  • Seizure-to-Spazzing Out ratio
  • Sterile-to-Staph aureus time
  • Sedation-to-Somnolence ratio
  • Sometin' Really Bad-to-Steroids time
  • Sometin' Really Bad-to-Surgery Consult time
  • Spit-to-Sputum Sample ratio
  • Stick Around For 3 Midnights-to-SNF ratio
  • Stupid-to-Sedation time

T

  • 10/10 Pain-to-Tylenol ratio
  • Tachycardia-to-Telemetry time
  • Too Obese For Ortho Consult rate
  • Too Old For Ortho Consult rate
  • Tourniquet-to-Transfusion ratio 
  • Train Wreck-to-Transfer time
  • Trash Talking About Transfers To Other Floors ratio
  • Trauma-to-Transfer time 
  • Trauma Drama-to-Totally Unnecessary Admission ratio

U

  • UTI-to-Urology Consult ratio
  • Urine Output-to-U Don't  Have To Worry About It ratio
  • Urosepsis-to-You've Got To Be Kidding Me ratio

V

  • Vague Complaints-to-Van time
  • Vanishing Vein-to-Victory time
  • Venereal-to-Valcyclovir time
  • Very Sick-to-Vital Signs time
  • Very Sick-to-Ventilator time
  • Veteran-to-Viagra ratio
  • Vindictive-to-Ventilator time
  • Violent-to-Versed time
  • Virgin-to-Venereal Disease ratio
  • Vocal-to-Ventilator time
  • Vomiting-to-Vital Signs time
  • Vulgar-to-Versed time

W

  • Waiting at the Nurses Station For Discharge-to-WTF time
  • Walking the Halls-to-Won't Go Home ratio
  • Weakness-to-Wonder If We'll Find Something This Time ratio
  • Weakness-to-Worthless Workup ratio
  • Weekend-to-Waiting time
  • Worthless Workup-to-Work Note Request time

X

  • X ray-to-Expect Result time

Y

  • Yeast-to-You Need a Nursing Home ratio
  • Your Baby Daddy Sent You-to-You're Not Getting A Pregnancy Test On My Time time 
  • Young-to-You're Making Me Yawn time
  • You're Irritating Me-to-Yankhauer time

Z

  • Zonked-to-Xanax ratio

"My ER has the highest Percocet-to-Perfect Press Ganeys in the country.  Just so you know."

My ER has the highest Percocet-to-Perfect Press Ganeys in the country.  Just so you know nurse ecard humor photo.


"We have the fastest Dialysis-to-Denny's Discharge time in the country.  Just so you know."

We have the fastest dialysis to Denny's discharge time in the country nurse ecard humor photo.


"My floor has the best anxiety to Ativan time in the country.  Just so you know."

My floor has the best anxiety to Ativan time in the country.  Just so you know photo. Medical Humor Store Banner


"At my hospital we have the best irritation to intubation time in the country.  Just so you know."

At my hospital we have the best irritation to intubation time in the country.  Just so you know doctor ecard humor photo. Medical Humor Store Banner



"At my ER, we have the fastest Percocet-to-Pork Sandwich time in the country.  Hurray!"

At my ER, we have the fastest Percocet-to-Pork Sandwich time in the country.  Hurray nurse ecard humor photo.


You can find hundreds of other original medical e-cards on Pinterest from The Happy Hospitalist too.

This post is for entertainment purposes only.  It contains humor that may only be understood by some healthcare professionals.  Read at your own risk.  If you believe any of this is real, we have a hospital quality measure that's just right for you.  It's called Geodon-to-God Made You Special Too ratio.



New and Established Patient E/M Definitions (CMS vs. CPT®)

I get lot of requests from readers of The Happy Hospitalist asking how to know if a patient is a new or established patient.  Identifying the correct classification will prevent delays or denials of payment.  Many evaluation and management (E/M) codes are by definition described as new or established.  This lecture will attempt to explain various important clinical aspects related to this determination.  Keep in mind while the Centers For Medicare & Medicaid Services (CMS) uses  Current Procedural Terminology (CPT) codes, CMS definitions do not always agree with CPT® definitions.  This discrepancy often leads to confusion for practitioners.  I will attempt to provide some insight into these differences as well.  I am a practicing clinical hospitalist with over ten years of experience and I understand how complicated these E/M rules can be.  I have written an extensive collection of CPT® and E/M lectures to help physicians and other non-physician practitioners (NPP) navigate the complex rules of medical billing and coding.  The Medicare Evaluation and Management Services Guide on page six defines a qualified NPP as nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants.

CPT® DEFINITION OF NEW VS. ESTABLISHED PATIENTS


The CPT® definition of a new patient underwent subtle changes in 2012.  Unfortunately, CMS did not change their definition to stay aligned with these changes.  This difference in language has caused great confusion for many qualified healthcare practitioners trying to stay compliant with the complex rules and regulations of  E&M.  I encourage all readers to have a handy copy of  the American Medical Association's CPT® manual for quick and easy reference.  The 2014 standard edition manual is available for purchase from Amazon by clicking on the image to the right.  How does the 2014 CPT® manual define a new patient?
A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.  
Let's look at this definition a little closer.  The 2014 CPT® manual defines professional services as those face-to-face services provided by physicians or other qualified health care professionals who may report an E/M service by a specific CPT® code.  In other words, if you provided a service, such as interpretation of an EKG or you read an echo, or you called in a prescription but you did not provide a billable E/M face-to-face encounter, the patient is still considered a new patient by the definition of professional services.  The 2012 updated definition of a new patient also added in the the words exact as well as and subspecialty.  Unfortunately, CMS did not change their definition to recognize this change in specialty determination.

     CPT® DEFINITION DECISION TREE


Decision trees may provide an easier way for qualified practitioners to understand these rules.  A new vs. established patient decision tree analysis is provided here, as it is in the CPT® manual.

Decision tree new vs old patient CPT definition


CMS DEFINITION OF NEW VS. ESTABLISHED PATIENTS


CMS provides insight into their definition of new versus established patients in several important resources.  These definitions are not the same as the updated 2012 CPT® definition.  First, a CMS definition of a new patient is provided in section 30.6.7 of Chapter 12 of the Medicare Claims Processing Manual (pdf page 52). From section A:

Definition of New Patient for Selection of E/M Visit Code 
Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Page 7 of the Evaluation and Management Services Guide also provides definitions of new and established patients.
For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.  
 A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years. 
An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years.
Both definitions lack the updated CPT® definition that includes the exact same specialty and subspecialty.  This has lead to great confusion when trying to define when a patient is new vs. established within the same group practice but of different specialty or subspecialty.  For patients not covered by Medicare, knowing how the insurance carrier reconciles this difference may prevent delays or denials of claims.

DEFINITION OF A GROUP PRACTICE (CMS)


One must also know how to define a group practice to interpret the new and established patient rules.  Medicare has defined a group practice in Chapter 5 of Medicare General Information, Eligibility, and Entitlement.  Section 90.4 (pdf page 38) says:
A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:
  • In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel; 
  • For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;
  • In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and 
  • Which meets such other standards as the Secretary may impose by regulation to implement §1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners.

This Medicare carrier further clarifies the definition of a group practice by stating we determine whether physicians are members of the same group based on the Tax Identification Number.  They also have an assortment of other clinically relevant scenarios in question and answer format.  I encourage all readers to review them for their own educational value.

RECOGNIZED MEDICARE SPECIALTIES


What specialties does Medicare recognize?  This list can be found in Chapter 26 of the Medicare Claims Processing Manual in Section 10.8.2 (starting on page 37).
Physicians are allowed to choose a primary and a secondary specialty code. If the carrier and DMERC provider file can accommodate only one specialty code, the carrier or DMERC assigns the code that corresponds to the greater amount of allowed charges. For example, if the practice is 50 percent ophthalmology and 50 percent otolaryngology, the carrier/DMERC compares the total allowed charges for the previous year for ophthalmology and otolaryngology services. They assign the code that corresponds to the greater amount of the allowed charges. 
Effective April 1st, 2012, these are the 63 recognized physician specialty codes.  Medicare provides a definition of each recognized specialty here.
  • 01  General Practice
  • 02  General Surgery
  • 03  Allergy/Immunology
  • 04  Otolaryngology
  • 05  Anesthesiology
  • 06  Cardiology
  • 07  Dermatology
  • 08  Family Practice
  • 09  Interventional Pain Management
  • 10  Gastroenterology
  • 11  Internal Medicine
  • 12  Osteopathic Manipulative Medicine
  • 13  Neurology
  • 14  Neurosurgery
  • 16  Obstetrics/Gynecology
  • 17  Hospice and Palliative Care
  • 18  Ophthalmology
  • 19  Oral Surgery (dentists only)
  • 20  Orthopedic Surgery
  • 21  Cardiac Electrophysiology
  • 22  Pathology
  • 23  Sports Medicine
  • 24  Plastic and Reconstructive Surgery
  • 25  Physical Medicine and Rehabilitation
  • 26  Psychiatry
  • 27  Geriatric Psychiatry
  • 28  Colorectal Surgery (formerly proctology)
  • 29  Pulmonary Disease
  • 30  Diagnostic Radiology
  • 33 Thoracic Surgery
  • 34  Urology
  • 35  Chiropractic
  • 36  Nuclear Medicine
  • 37  Pediatric Medicine
  • 38  Geriatric Medicine
  • 39  Nephrology
  • 40  Hand Surgery
  • 41  Optometry
  • 44 Infectious Disease
  • 46  Endocrinology
  • 48  Podiatry
  • 66  Rheumatology
  • 70  Single or Multispecialty Clinic or Group Practice
  • 72  Pain Management
  • 73  Mass Immunization Roster Biller
  • 76  Peripheral Vascular Disease
  • 77 Vascular Surgery
  • 78  Cardiac Surgery
  • 79  Addiction Medicine
  • 81  Critical Care (Intensivists)
  • 82  Hematology
  • 83  Hematology/Oncology
  • 84  Preventative Medicine
  • 85  Maxillofacial Surgery
  • 86  Neuropsychiatry
  • 90  Medical Oncology
  • 91  Surgical Oncology
  • 92  Radiation Oncology
  • 93  Emergency Medicine
  • 94  Interventional Radiology
  • 98  Gynecological/Oncology
  • 99  Unknown Physician Specialty
  • C0  Sleep Medicine


RECOGNIZED AMA SPECIALTIES AND SUBSPECIALTIES


What about other specialties or subspecialties not recognized by Medicare?  Here are several nice resources reviewing AMA physician specialty codes

DIFFERENCE BETWEEN CPT® AND CMS CAUSING CONFUSION


Clearly, these differences in how a new vs. established patient are defined has caused great confusion for providers.  This April 15th, 2011 letter to CMS from the AMA provides further insight into the confusion.

NEW VS. ESTABLISHED PATIENT DETERMINATION DOES NOT APPLY


By CPT® definition, not all E/M codes require the qualified practitioner to determine if the patient is new or established. Which common E/M code groups are excluded from the new patient vs. old patient determination?
  • Initial observation care (99218-99220)
  • Subsequent observation care (99224-99226)
  • Observation care discharge services (99217)
  • Initial hospital care (99221-99223)
  • Subsequent hospital care (99231-99233)
  • Admission and Discharge Services same day (99234-99236)
  • Hospital discharge services (99238, 99239)
  • Critical care services (99291, 99292)
  • Emergency department services (99281-99285)
  • Initial nursing facility care (99304-99306)
  • Subsequent nursing facility care (99307-99310)
  • Inpatient consultations (99251-99255).  This code group is no longer recognized by CMS.
  • Office or other outpatient consultations (99241-99245).  This code group is no longer recognized by CMS.

NEW VS. ESTABLISHED PATIENT DETERMINATION DOES APPLY


By CPT® definition, some E/M codes require the practitioner to determine whether the face-to-face encounter involves a new patient or an established patient.
  • Office or other outpatient services new patient (99201-99205)
  • Office or other outpatient services established patient (99211-99215)
  • Domiciliary, rest home (eg, boarding home), or custodial care services new patient  (99324-99328)
  • Domiciliary, rest home (eg, boarding home), or custodial care services established patient (99334-99337)
  • Home services new patient (99341-99345)
  • Home services established patient (99347-99350)
  • Preventative medicine services new patient (99381-99387)
  • Preventative medicine services established patient (99391-99397)

NEW VS. ESTABLISHED CLINICAL EXAMPLES IN THE HOSPITAL 


Most E/M code groups used in the hospital do not require the practitioner to determine whether the patient is new or established in their group practice.  However, one common hospital billing and coding scenario does require quite a bit of effort to determine the correct E/M code group.  As a consultant caring for a Medicare patient in the hospital under ambulatory surgery center (ASC) or observation status, practitioners are directed to use the office or other outpatient service codes.   This also applies to any other patient who's insurance does not accept consultation codes.  Determining whether the patient is a new patient or an established patient is necessary to prevent delays or denials in payment.
A 42 year old morbidly obese man with chronic lymphedema and a diagnosis of bilateral cellulitis is admitted to observation status by a hospitalist in a different group as a direct admission from the primary care physician's office with a request to consult an infectious disease specialist.
In this scenario, the hospitalist would use the attending physician initial observation code group 99218-99220 for the admission,  code group 99224-99226 for subsequent care visits and 99217 for the date of discharge.  However, the infectious disease (ID) consultant would first have to know whether the patient's insurance carrier accepts consultation codes.  If they do, the initial encounter should be coded as an outpatient consultation (99241-99245).  All subsequent care visits should be coded as office or other outpatient services of an established patient (99211-99215).

However, if the patient's insurance does not accept consultation codes, then the ID consulting specialist must determine whether the patient is a new patient or an established patient in their group practice.  If the ID specialist determines the patient is new, they should bill their initial encounter as an office or other outpatient service of a new patient using code group 99201-99205.   If they determine the patient is an established patient of their group practice, they should choose the office or other outpatient service established patient code group 99211-99215 as their initial and all subsequent care visits.  Here is another clinical example.
A healthy 37 year old with stable seasonal allergies is admitted under ASC status by an orthopedic surgeon for shoulder surgery.  The hospitalist is consulted for medical management.
What should the hospitalist bill? The hospitalist must follow the same decision analysis as the ID specialist did in the clinical example above.  Most hospitalists do not have their own office charts or EMR to reference when trying to determine if they have seen the patient in the last three years.  The only way to know for sure whether any other hospitalist or other physician of the same specialty or non-physician practitioner (NPP) working with the same specialty in the same group practice has seen the patient in the last three years is to search their hospital's EHR for evidence of any prior H&P, consult note or other face-to-face E/M progress note visit that would qualify as a professional service.  Most doctors don't have the time, energy, education or resources to figure all that out.  

NEW VS. ESTABLISHED CLINICAL EXAMPLE IN THE OFFICE 


Excluding consultation codes, choosing new vs. established codes in the office is straight forward.  Either the patient is or isn't a new patient based on the prevailing rules of the patient's third party payer.  If the patient is a new patient, choose code group 99201-99205 for the initial encounter and 99211-99215 for subsequent established care visits until it is determined the patient is no longer an established patient.  If the patient is not a new patient, established care codes should be used.

If consultation codes are allowed by the patient's insurance company, then code group 99241-99245 should be used for the consult request.  Depending on whether a transfer of care is made or not, subsequent visits should be coded using either this same consult code group or the office established patient code group (99211-99215).
A 78 year old Medicare patient is referred by the primary care physician to a cardiology group for chest pain.  A stress test, ordered the day prior, was read as abnormal by a different cardiologist in the same group practice.  
What should the cardiologist code for their initial E/M encounter?   Based on the Medicare definition detailed above, reading of a stress test does not constitute professional services.   It should be ignored when determining whether the patient is new or established.  In addition, Medicare does not recognize consult codes.  Cardiology is a Medicare recognized specialty.   If the patient has received any professional services (E/M service or other face-to-face service) by any cardiologist or NPP working under the direction of the cardiologist or any other cardiologist in the same group practice in the last three years, only the established patient clinic code group 99211-99215 can be used.   If no cardiologist or NPP working with a cardiologist in this group practice has seen the patient in the last three years, then the patient is a new patient.  Code group 99201-99205 should be used for the initial visit.

NURSE PRACTITIONER AND PHYSICIAN ASSISTANT E/M VISIT SCENARIO


Qualified non-physician practitioners are considered part of the group practice and specialty for which they provide service along with physicians in the same specialty and group practice.  In fact, Medicare's E/M Services Guide (on page 7 linked above) states quite clearly that non-physician practitioners are treated the same as physicians as providers of professional services over the three year time frame.   Even the CPT® definition bundles the physician with qualified health care professional in their definition of new vs. established patients.   In addition, the 2014 CPT® manual says
When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.

ON CALL AND CROSS-COVERING PROFESSIONAL SERVICES SCENARIO


If a physician or other qualified NPP is providing cross-cover care for another physician, how does this affect the new or established patient decision?  The answer to this question has been answered by WPS, a Medicare contractor.
In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.
The 2014 CPT® manual says
In the  instance where a physician/qualified health care professional is on call for or covering for another physician/qualified health care professional, the patient's encounter will be classified as it would have been by the physician/qualified health care professional who is not available.  
I find this guidance interesting and conflicting with the definition of a new patient.  If one solo practitioner is providing coverage for another solo practitioner in a different group practice, they have different tax identification numbers.  By their own admission, Medicare states they audit the new vs. established patient decision based on the tax identification number.  Their computer algorithms may not be able to establish an on call or cross-covering scenario in situations where two physicians, whether of like specialty or not, of different groups with different tax identification numbers, are providing coverage for each other.

When would this scenario occur?  Consider the hospital observation scenario where one physician is providing on call services for another physician and they are asked to consult on a Medicare observation patient being admitted to the hospital by another group practice.  It may be possible the on call physician has not seen the patient in the last three years but the patient's normal physician has.  Should the cross-covering physician bill for a new patient encounter or an established patient encounter?  According to CMS and CPT® guidance, the on call physician should bill as if they were the patient's normal physician.   However, if they choose to bill the E/M visit as a new patient encounter, it may be difficult for  computer algorithms to identify this coding error  due to the different tax identification numbers used by both physicians.  In fact, the covering physician wouldn't even know whether the patient had professional services provided by the patient's normal physician in the prior three years as they probably would not have access to their office records.

MULTIPLE PRACTICE SITES, SAME TAX ID SCENARIO


Consider the scenario where a family practice group has multiple sites of care all billing under the same tax identification number.   Each site has their own patient records that are not available at other clinic sites.  The patient is now being evaluated at a clinic site by a different physician or NPP who has never seen the patient and has no records available.   Should this patient be coded as a new patient or an established patient?  If a patient has been seen in the previous three years by any physician or NPP in the same group and specialty, regardless of which clinic site they went to and regardless of whether patient records are available, only established patient codes should be used.  CMS and CPT® rules do not provide exceptions to practice sites that do not have access to records.

Site of service also does not apply if the patient received professional services in the hospital or in the emergency department.  Consider the scenario where Physician A provides inpatient hospital care for a patient.  The patient has never been seen previously by Physician A or any other physician or NPP in the same specialty and same group practice of Physician A.  The patient is discharged and fails to follow up as requested.  Two years later the patient calls the office of Physician A requesting to establish care in the clinic with Physician A.  Because Physician A has provided professional services in the last three years, the patient is considered an established patient, regardless of which physician or NPP in the in the same specialty and group practice provides the care.

CHANGE IN GROUP PRACTICE SCENARIO


How should a physician or NPP code patients after they have left one group practice and joined another?  Under a new group or solo practice, the physician would have a new tax identification number.  However, the definition of a new patient says they cannot have received professional services in the last three years from the physician or qualified health care professional.  Some payer algorithms may not be able to identify the new vs. established patient decision for physicians or NPP who change tax identifications.  Some may.  To bill and code correctly the correct interpretation of this scenario says to bill established patient care codes if the physician or NPP has seen the patient for professional services in the last three years.

What if a physician changes groups and one of their established patients is seen in the new group for the first time by a physician or non-physician practitioner in the new group who has never seen the patient and has no records on the patient?  Since the patient is established to the physician new to the group, the patient is established to all physicians and qualified health care professionals in the group.  Established care codes should be used.

RECOVERY AUDITORS AND NEW PATIENT CODES


Physicians and other non-physician practitioners should be aware that Recovery Auditors, under contract from CMS, are specifically targeting improper payments involving new patient claims when the beneficiary does not meet defined criteria to be a new patient.  Medicare Learning Network document MM8165 says
As a result of overpayments for new patient E&M services that should have been paid as established patient E&M services, CMS will implement changes to the Common Working File (CWF) to prompt CMS contractors to validate that there are not two new patient CPTs being paid within a three year period of time.  
Which codes will be checked?  This document further clarifies which codes the Recovery Auditors will be checking.
The new patient CPT codes that will be checked in these edits include 99201- 99205, 99324 - 99328, 99341 - 99345, 99381 - 99387, 92002, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211 - 99215, 99334 - 99337, 99347 - 99350, 99391 - 99397, 92012, and 92014) .
Given the desire of CMS to recuperate overpayments and the complexity of the rules to follow, I encourage all physicians to be diligent in determining when their patient is a new patient or an established patient by CMS criteria.

RVU OF NEW AND ESTABLISHED CLINIC PATIENTS


What is the difference in relative value unit (RVU) for the new and established common outpatient clinic codes?  In 2014, the work RVU (wRVU) values of these common codes are described here.  I have provided a more detailed RVU and dollar analysis at each linked CPT® lecture below.  As you can see, the difference in work RVU value (and total RVU value) is quite significant for similar levels of service when comparing new vs. established care codes.

      MID-LEVEL OFFICE VISIT
  • 99203 (new) wRVU = 1.42
  • 99213 (established) wRVU = 0.97
      MID-HIGH LEVEL OFFICE VISIT
  • 99204 (new) wRVU = 2.43
  • 99214 (established) wRVU = 1.50
      HIGH LEVEL OFFICE VISIT 
  • 99205 (new) wRVU = 3.17
  • 99215 (established) wRVU = 2.11


LINK TO E/M POCKET REFERENCE CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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