Priority Management Group – CHC Billing Experts

How would you handle a billing process for lost EMR/Paper documentation of an office visit?  An incident occurred where a provider’s documentation was initiated but part or all of the information is missing.  IT staff had our Vendor look into this and the documentation cannot be restored.
As a Billing Manager I went to provider and discussed the partial missing information. The feeling of the provider was that the patient was seen. He would document that the information was lost and due to lapse in time, he cannot recall specific information. The provider stated I should still bill out the visit as patient was seen. How can I bill the visit out when the documentation does not support the level of service?  The provider appended note and added diagnosis codes but there is not a HPI or PE however he will append again to put in “documentation was lost”.

Should this happen again, are there any policies, procedures that I can give the provider and have myself for documentation and for billing?

Thanks for the note. To my knowledge, this is new and uncharted territory due to EMR but in reality the same could have happened with paper records. However, as with any such situation, if there is evidence the patient was seen AND a note to indicate all or a portion of the record has been lost/misplaced (and am assuming this note/addendum is dated in the present so it is clear there is no inappropriate retrospective “re-creation” of documentation), do not think you will have issues with payers. If you feel you want to down-code the service, that is your option but I think overkill. If still very concerned, you can always consult your organization’s legal counsel.

Our state recently told us that we can’t bill a 99211 done by an RN unless a midlevel or a Dr. is onsite.  We hadn’t heard this before.  Have you heard this?  We commonly bill a 99211 if the client is seen by an RN and the client is already established.

Assuming (and this is dangerous) the state is following the federal “incident to” guidelines (set forth initially in 1992) they require physical presence (and Medicare has clarified this to mean “within shouting distance”) of the provider under whose name the claim will be billed, therefore on-site. It is overlooked (ignored) by scores (I daresay thousands) of practices across the country as the 99211 is for most simply the code used for a non-billable provider visit; i.e., covers any multitude of services from conversation about diagnostic outcomes, simple walk-in issues not requiring a billable clinician, brief educational sessions, etc.  However, in the end, if following these federal rules, the billable provider must be on-site.

To your question, please remember that the “incident to” guidelines pertain only to Medicare in the fee-for-service (FFS) world in terms of using a different NPI. In a FQHC, Medicare is payable via the encounter rate which is based on face-to-face encounter between a patient and a “core provider.” The core provider can be a physician or a “non-physician practitioner” (NPP).  A NPP is defined as a Nurse Practitioner, Physician Assistant, or Certified Nurse Mid-wife. There is no reduction in payment (as in the FFS world) world when being compensated for “encounter rate.” Further, the restrictive “incident to” guidelines are Medicare FFS only which means you should not automatically apply these to Managed Medicaid, encounter rate (PPS) Medicaid, or other commercial plans unless you determine, in writing, that they follow Medicare’s explicit statutes.  However, since the Medicare “incident to” guidelines are quite conservative, it is a very safe way to interpret how to bill a NPP under a doctor’s NPI.

As most of you are aware, Medicare postponed implementation of edits to deny claims when/if the ordering/referring provider is either not enrolled in Medicare and/or does not have a current PECOS record.  There were a great many questions as to why this was required for FQHC providers as they are reimbursed at the all-inclusive rate and do not require individual provider enrollment applications.

CMS has now published guidance for those providers that ‘infrequently receive reimbursement from the Medicare program.’  One of the specific provider types mentioned is those employed at an FQHC.   They have abbreviated the application process but it indicates that it must be completed on paper and include a letter to advise that it is for the sole purpose of ordering/referring services for Medicare beneficiaries and CANNOT be reimbursed for services performed. 

While it sounds like they were being sensitive to the facts, it does not eliminate the need to complete the full 855I and R to capture payment for any services that are carved out of the FQHC Medicare contract. 

Here is the link and there are a few included in the document that you may want to check out.  I haven’t read through them all but will do so.  I also haven’t seen when the edit will be put into place as a final rule but we need to get ahead of the curve, just in case.

http://www3.cms.gov/MedicareProviderSupEnroll/Downloads/SpecialEnrollmentFactsheetInfrequentPhysicianReimbursement.pdf

By: Kristie Sell Viveiros, CPC, VP of Billing Operations Priority Management Group, Inc

We have a question – v72.40 – pregnancy unconfirmed, v72.41 pregnancy negative test, v72.42 pregnancy, positive test

Patients come in and wants to know if they are pregnant. We do the pregnancy test (HCG) this test will either read out negative or positive – we have used the above dx codes v72.41(Neg) or v72.42(Pos).  If a provider does this test and then wants to confirm the test by doing a venipucture and sends out to lab then we use the v72.40.

I have read in the coders desk reference that you would only use the above dx codes if there was absence of a symptom. I have also been told that we should be using v72.40 for every HCG test as these test are not fully accurate and most generally the provider will request a venipucture to have a confirmed dx of pregnancy.

I feel that the HCG is a test and we would be ok using v72.41 if test result is negative and v72.42 if test result is positive and if provider sends out the venipucture I would use v72.40.  If the pt came in and had symptoms then I would code symptoms for the HCG test.   

Can you give me your opinion on when we should and should not be using these dx codes?

Thanks for the note. In short, it is either positive or negative, period. This supports ACOG which says the “unconfirmed” option should be rarely used. In the family planning world, it is used to delay a confirmation to a third party payer or due to a need (desire) for ultrasound confirmation. However, the urine PT is pretty solid diagnostic evidence and patients either are, or are not, pregnant.