E/M coding for physicians was introduced along with the MPFS starting back in 1992. E/M coding for hospital outpatient services started with the implementation of APCs in 2000. The use of the E/M codes are quite different between physicians and hospitals. Physicians code for what they do using mainly the history, examination and medical decision making as guides. There is guidance for physicians in the CPT Manual as well as separate guidelines from CMS. Hospital E/M coding is based on resources used and is thus quite different. When APCs were implemented in 2000 CMS did not have guidelines relative to coding the resources utilized. As a result, CMS directed hospitals to develop their own mappings and to then use them. In the meantime CMS was supposed to develop guidelines, but for 2014 CMS made the surprising move to institute a single HCPCS code, namely G0463, for the ten clinic level visits. This move was a major mistake now that we have Section 603 clinics from BiBA 2015 by which off-campus provider-based clinics at to be paid at the freestanding clinic rate.
This workshop explores E/M coding for both physicians and hospitals and include a brief discussion of consultation codes for telehealth. Documentation issues and challenges relative to auditing E/M coding discussed for both physicians and hospitals. Compliance issues and concerns are discussed relative to E/M coding. The use and misuse of the “-25” modifier along with other modifiers surrounding E/M coding the global surgical package. Audit techniques are outlined relative to assuring proper compliance with E/M coding.
Possible changes to E/M coding for Medicare for CY2019 will be addressed. While significant changes for the office visits (99201-99215) have been proposed, the final changes will be announced in the first half of November, 2018.
- Understand How Physicians and Hospitals Use E/M Codes
- Appreciate the Need to Review E/M Coding and Judge Associated Documentation
- Learn About the CMS Facility E/M Coding Principles and the G0463
- Understand the Difficulties with E/M Coding for the ED
- Appreciate How To Adjust to CMS Dropping the Consultation Codes
- Appreciate the Differences Between Specialty Clinic Coding and Primary Care Clinic Coding for E/M Services
- Appreciate Documentation System Including ‘Copy and Paste’ Capabilities
- Understand the Interplay Between Facility component E/M Coding and Physician E/M Coding
- Learn About the Difference Between a ‘New’ Patient versus an ‘Established’ Patient
- Understand How to Organize an E/M Coding Audit for Either Physicians or Hospitals
- Understand the Importance of the “-25” Modifier
- Appreciate the Compliance Challenges Surrounding E/M Coding
- Learn About Changes in Office Visit for Medicare for CY2019
- To review the E/M codes as they appear in the CPT Manual.
- To explore different guidelines that are used by physicians and hospitals.
- To understand the use of G0463 and BBA 2015 Section 603 clinics.
- To discuss establishing an E/M coding audit and audit program.
- To appreciate the difference between ‘new’ versus ‘established’ patients for physicians and hospitals.
- To appreciate physician coding for incident-to billing.
- To understand the differences in E/M coding for ER physicians and provider-based clinic physicians both primary care and specialty.
- To appreciate the physician E/M documentation guidelines.
- To explore the compliance challenges faced by both physicians and hospitals for E/M coding and the “-25” modifier.
- Recognize how to make changes to accommodate CMS’s dropping the use of the consultation codes.
- To explore how electronic health record systems create challenges for developing proper documentation to support E/M coding.
- To review changes that are being made for office visit E/M codes for Medicare starting in 2019.
- E/M Coding Under RBRVS
- E/M Coding Under APCs
- E/M Codes – General Categories
- Physician Use of E/M Codes
- Electronic Health Record Systems
- Update to Office Visit Codes for Medicare
- CMS Proposal for Special G-Codes
- Changes in Documentation Guidelines
- E/M Coding Guidelines
- Physician Guidelines
- Hospital Developed Guidelines
- BBA 2015 Section 603 Clinics
- Variations for ED and Provider-Based Clinics
- Consultation Code Issues and the “-AI” Modifier
- CMS Coding System Principles and Guidance
- CMS Guidelines
- CMS Audit Criteria
- CMS Expectaion
- Planning An E/M Coding Audit
- Overall Objective
- Number of Cases For Selection
- Stratification of E/M Levels
- Use of OIG’s RAT-STATS Program
- Audit Guidelines
- Developing Recommendations
- Assessing Impact of Electronic Health Record Computer Systems
- Report Writing and Recommendations
- Case Studies/Exercises
- Sources for Further Information
- Clinic Managers
- Clinic Administrators
- Coding Personnel
- Billing and Claims Transaction Personnel
- Nursing Staff
- Clinical Service Area Personnel
- Chargemaster Coordinators
- Financial Analysts
- Compliance Personnel
- Non-Physician Practitioners
- Healthcare Auditors
- Other Interested Personnel
About the Presenter:
Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in healthcare and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. Dr. Abbey works extensively in all areas relating to compliance reviews, coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.
In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.
Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.
Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding & Billing: A Guide to Reimbursement & Compliance published.
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