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Code for Documentation!   Audit for Compliance! Richard J Hamburger MD Professor Emeritus of Medicine Indiana University Indianapolis IN Debra H. Lawson, CPC, PCS Nephrology Billing & Management  Services, LLC Rogersville, TN
Objectives     interaction requested ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ESRD Codes Where are we? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
End Stage Renal Disease Services  (ESRD) ,[object Object],[object Object],[object Object]
What are we trying to capture? ,[object Object],[object Object],[object Object],[object Object],[object Object]
Approach to the family ,[object Object],[object Object],[object Object],[object Object],[object Object]
End-Stage Renal Disease Services ,[object Object]
End-Stage Renal Disease Services ,[object Object]
End-Stage Renal Disease Services ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adult In Center codes:  > 20 y.o. ,[object Object],[object Object],[object Object],[object Object]
End-Stage Renal Disease Services ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pediatric In Center codes: <2 y.o. ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pediatric Home Dialysis codes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MCP GUIDELINES A POLICY REVIEW
MONTHLY CAPITATION PAYMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MONTHLY CAPITATION PAYMENT ,[object Object],[object Object],[object Object],[object Object],[object Object]
MONTHLY CAPITATION PAYMENT ,[object Object],[object Object],[object Object]
MONTHLY CAPITATION PAYMENT ,[object Object],[object Object],[object Object],[object Object]
OUTPATIENT SETTINGS ,[object Object],[object Object],[object Object]
PRACTITIONER DEFINITIONS ,[object Object],[object Object],[object Object],[object Object]
USE OF NON-PHYSICIAN PRACTITIONERS ,[object Object],[object Object],[object Object],[object Object]
PARTIAL MONTH RULE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PARTIAL MONTH RULE ,[object Object],[object Object],[object Object]
TRANSIENT PATIENTS ,[object Object],[object Object],[object Object]
PATIENTS WITH LESS THAN A FULL MONTH MCP ,[object Object],[object Object],[object Object],[object Object],[object Object]
HOSPITAL OBSERVATION STATUS ,[object Object],[object Object],[object Object]
HOSPITALIZATION  & the  MCP  in  IN-CENTER PATIENTS ,[object Object],[object Object],[object Object]
HOME DIALYSIS ,[object Object],[object Object],[object Object],[object Object]
HOME DIALYSIS ,[object Object],[object Object]
HOSPITALIZATION  & the   MCP - HOME DIALYSIS ,[object Object],[object Object]
TEACHING PHYSICIANS ,[object Object]
TEACHING PHYSICIANS ,[object Object],[object Object],[object Object],[object Object]
MODALITY CHANGES ,[object Object],[object Object]
CHANGES IN DOCUMENTATION REQUIREMENTS ,[object Object],[object Object],[object Object]
CHANGES IN DOCUMENTATION REQUIREMENTS (cont) ,[object Object],[object Object],[object Object]
ADDITIONAL DOCUMENTATION NEEDED FOR PEDIATRIC PATIENTS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CHANGES IN DOCUMENTATION REQUIREMENTS (cont) ,[object Object],[object Object],[object Object]
IMPORTANT TIP! ,[object Object],[object Object]
HOME DIALYSIS  TRAINING
HOME TRAINING DIALYSIS MANAGEMENT ,[object Object],[object Object],[object Object]
HOME TRAINING DIALYSIS MANAGEMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
HOME TRAINING DIALYSIS MANAGEMENT ,[object Object],[object Object],[object Object]
Infusion Codes ,[object Object],[object Object],[object Object]
CONSULT  V  REFERRAL CORRECT CODING CAN MEAN $$$$ INCORRECT CODING….
CONSULTATION ,[object Object],[object Object],[object Object]
CONSULTATION ,[object Object]
Concurrent Care and Transfer of Care Currently accepted for CPT 2010 ,[object Object]
Concurrent Care and Transfer of Care Currently accepted for CPT 2010 ,[object Object]
Concurrent Care and Transfer of Care Currently accepted for CPT 2010 ,[object Object]
Concurrent Care and Transfer of Care Currently accepted for CPT 2010 ,[object Object]
Concurrent Care and Transfer of Care Currently accepted for CPT 2010 ,[object Object],[object Object]
CONSULTATION ,[object Object],[object Object],[object Object]
CONSULTATION ,[object Object],[object Object]
NON-PHYSICIAN PRACTITIONERS & CONSULTS  ,[object Object],[object Object],[object Object]
NON-PHYSICIAN PRACTITIONERS & CONSULTS ,[object Object],[object Object]
PRE-OPERATIVE CLEARANCE ,[object Object],[object Object],[object Object]
PRE-OPERATIVE CLEARANCE ,[object Object],[object Object],[object Object],[object Object]
WHAT IS NOT A CONSULT ,[object Object],[object Object],[object Object],[object Object]
REFERRAL ,[object Object],[object Object],[object Object]
CONSULTATION CODES ,[object Object],[object Object],[object Object]
USE OF HOSPITALISTS ,[object Object],[object Object],[object Object]
USE OF HOSPITALISTS ,[object Object],[object Object]
USE OF HOSPITALISTS ,[object Object],[object Object]
CONSULT TIDBITS ,[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object],[object Object],[object Object]
DISCHARGE  MANAGEMENT SERVICES
DISCHARGE CRITERIA ,[object Object]
DISCHARGE CRITERIA ,[object Object],[object Object],[object Object],[object Object],[object Object]
DISCHARGE CRITERIA ,[object Object],[object Object],[object Object],[object Object]
DISCHARGE CRITERIA ,[object Object],[object Object],[object Object]
DISCHARGE MANAGEMENT ,[object Object],[object Object],[object Object],[object Object]
NEPHROLOGY  SPECIFIC  CPT  CODING
INPATIENT DIALYSIS CODES ,[object Object],[object Object],[object Object],[object Object],[object Object]
INPATIENT DIALYSIS CODES ,[object Object],[object Object],[object Object],[object Object]
INPATIENT DIALYSIS CODES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EXAMPLE:  DIALYSIS NOTE 90935 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EXAMPLE:  JUSTIFICATION 90937   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
90937 vs CRITICAL CARE WHEN IS EACH APPROPRIATE?
CODING FOR CRITICAL CARE
99291 ,[object Object]
99292 ,[object Object]
CPT DEFINITION  CRITICAL ILLNESS OR INJURY ,[object Object]
CPT DEFINITION  CRITICAL CARE SERVICES ,[object Object],[object Object]
CPT DEFINITION  CRITICAL CARE SERVICES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CPT DEFINITION  CRITICAL CARE SERVICES ,[object Object]
WHERE CRITICAL CARE  IS PROVIDED ,[object Object]
CRITICAL CARE  TREATMENT CRITERION ,[object Object],[object Object]
CRITICAL CARE  “FULL ATTENTION” REQUIREMENT ,[object Object]
WHERE IS CRITICAL CARE PROVIDED ,[object Object],[object Object],[object Object]
CRITICAL CARE DOCUMENTION  FOR MEDICAL REVIEW ,[object Object],[object Object],[object Object],[object Object]
SERVICES  NOT  INCLUDED IN CRITICAL CARE TIME ,[object Object],[object Object],[object Object]
CRITICAL CARE & DIALYSIS ,[object Object],[object Object],[object Object]
CRITICAL CARE TIDBITS ,[object Object],[object Object],[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object],[object Object],[object Object]
TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Compliance  Assessment
Compliance Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Compliance Assessment ,[object Object],[object Object],[object Object],[object Object]
 
2009 Nephrology Specific PQRI Measures MEASURE NUMBER MEASURE DESCRIPTION REPORTING OPTIONS END STAGE RENAL DISEASE (ESRD) 79 Influenza Immunization in Patients with ESRD Claims, Registry 81 Plan of Care for Inadequate Hemodialysis  Registry 82 Plan of care for Inadequate Peritoneal Dialysis Registry CHRONIC KIDNEY DISEASE (CKD) 121 Laboratory Testing (calcium, phosphorus, intact parathyroid hormone (iPTH) and lipid profile) Claims, measures group (MG), and Registry 122 Blood Pressure Management Claims, MG, and Registry 123 Plan of Care for Elevated Hemoglobin for Patients Receiving ESA Therapy Claims, MG, and Registry 135 Influenza Immunization in Patients with CKD Claims, MG, and Registry 153 Referral for AV Fistula Claims, MG, and Registry
2009 Claims Based Reporting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
03 17  09  03 17 09  11  99213  1  50 00  123456789  03 17  09  03 17 09  11  3278F  1  0 00  123456789  585.5 03 17  09  03 17 09  11  3281F  1  0 00  123456789  Make sure that diagnosis is included in the PQRI measure specifications Each PQRI measure must have individual NPI # PQRI claims MUST contain a service (CPT) code that is included in the PQRI measure denominator 03 17  09  03 17 09  11  4171F  1  0 00  123456789  03 17  09  03 17 09  11  4037F  1  0 00  123456789
PQRI and eRx resources available on RPA’s website ,[object Object],[object Object],[object Object]
Compliance Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]
BILLING FOR  ERYTHROPOIETIC STIMULATING AGENTS
CAUTION ! ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],INITIAL  ESA  (Epoetin Alfa &  Darbepoetin Alfa)   ADMINISTRATION  EXAMPLE   GUIDELINES
FOLLOW-UP ESA  (Epoetin Alfa &  Darbepoetin Alfa)   ADMINISTRATION  EXAMPLE   GUIDELINES ,[object Object],[object Object],[object Object],[object Object]
COMPLETING HCFA 1500 Form ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DRUG CODES ,[object Object],[object Object],[object Object],[object Object]
BILLING FOR  ADMINISTRATION OF  ESA ,[object Object],[object Object],[object Object]
BILLING FOR  ADMINISTRATION OF  ESA ,[object Object],[object Object]
CHANGES IN BILLING FOR ESA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CHANGES IN BILLING FOR ESA ,[object Object],[object Object],[object Object],[object Object]

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07 Am09 Presentations Hamburger & Lawson

  • 1. Code for Documentation!  Audit for Compliance! Richard J Hamburger MD Professor Emeritus of Medicine Indiana University Indianapolis IN Debra H. Lawson, CPC, PCS Nephrology Billing & Management Services, LLC Rogersville, TN
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  • 39. HOME DIALYSIS TRAINING
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  • 44. CONSULT V REFERRAL CORRECT CODING CAN MEAN $$$$ INCORRECT CODING….
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  • 103. 2009 Nephrology Specific PQRI Measures MEASURE NUMBER MEASURE DESCRIPTION REPORTING OPTIONS END STAGE RENAL DISEASE (ESRD) 79 Influenza Immunization in Patients with ESRD Claims, Registry 81 Plan of Care for Inadequate Hemodialysis Registry 82 Plan of care for Inadequate Peritoneal Dialysis Registry CHRONIC KIDNEY DISEASE (CKD) 121 Laboratory Testing (calcium, phosphorus, intact parathyroid hormone (iPTH) and lipid profile) Claims, measures group (MG), and Registry 122 Blood Pressure Management Claims, MG, and Registry 123 Plan of Care for Elevated Hemoglobin for Patients Receiving ESA Therapy Claims, MG, and Registry 135 Influenza Immunization in Patients with CKD Claims, MG, and Registry 153 Referral for AV Fistula Claims, MG, and Registry
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  • 105. 03 17 09 03 17 09 11 99213 1 50 00 123456789 03 17 09 03 17 09 11 3278F 1 0 00 123456789 585.5 03 17 09 03 17 09 11 3281F 1 0 00 123456789 Make sure that diagnosis is included in the PQRI measure specifications Each PQRI measure must have individual NPI # PQRI claims MUST contain a service (CPT) code that is included in the PQRI measure denominator 03 17 09 03 17 09 11 4171F 1 0 00 123456789 03 17 09 03 17 09 11 4037F 1 0 00 123456789
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