Thursday, July 25, 2019

CPT 21100, 21110, 21120,21121 - 21127 - Orthognathic surgery codes

CPT code and Description

21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121 Genioplasty; sliding osteotomy, single piece

21122 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)

21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125 Augmentation, mandibular body or angle; prosthetic material

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft


Description

Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw), the maxilla (upper jaw), or both.  When orthognathic surgery is indicated, it is generally after orthodontic treatment (braces), which is done in order to move the teeth into their new position. 

During the surgical procedure, the jawbones are repositioned to a more “normal” position; in some cases, bone may be added, removed, or reshaped.  Surgical plates, screws, wires and rubber bands may be used to hold the jaws in their new position.  The most common technique is known as the LeFort I (though there are variations of this technique that may be performed, depending on the exact indications for the surgery).

Orthognathic surgery is usually performed by both an oral and maxillofacial surgeon and an orthodontist.  The orthodontist will work to position the teeth in proper alignment and the oral and maxillofacial surgeon does the surgery as needed on the jaw joints and/or other facial bones.


Coverage Limitations
Humana members may NOTbe eligible under the Plan for orthognathic surgeryfor any indications other than those listed above. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.


Humana members may NOTbe eligible under the Plan for 3-D Computerized Tomography (CT) scan, including in the pre-planning phase of treatment.  This technology is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language


Criteria for a Coverage Determination as Reconstructive and Medically Necessary: 

A requested procedure will be deemed reconstructive and medically necessary and therefore covered when:

1. There is a physical abnormality and/or physiological abnormality that is causing a functional impairment that requires correction;and

2. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or restore the patient’s physiological function


DOCUMENTATION REQUIREMENTS

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.


Medical notes documenting all of the following:

** Comprehensive  history of the medical condition(s) requiring treatment or surgical intervention; including all of the following:

A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment; The physical and/or physiological abnormality has resulted in a functional deficit; The functional deficit is recurrent or persistent in nature

** Appropriate clinical studies/tests including cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable Radiologic film interpretations including lateral cephalometric  radiograph, AP radiograph and panoramic radiograph

** Clinical photographs of the member’s occlusion Diagnostic Polysomnography for obstructive sleep apnea surgery

** Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit

** History of previous non-surgical and surgical treatment (e.g.,obstructive sleep apnea


DEFINITIONS

The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable definitions.

Cancer Sequela: An aftereffect resulting from a cancer

Functional/Physical Impairment: A Physical/Functional or Physiological Impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Jaw Surgery: Surgical procedures to address facial trauma, neoplasms, facial clefts, surgical resection and iatrogenic radiation.


Orthognathic Surgery: The surgical correction of skeletal anomalies or malformations involving the mandible (lower jaw) or maxilla (upper jaw). These malformations may be present at birth or may become evident as the individual grows and develops. Causesinclude congenital or developmental anomalies.

Monday, July 1, 2019

CSHCS - Inital and ongoing comprehension evaluation basic


INITIAL COMPREHENSIVE EVALUATION

The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.


An Initial Comprehensive Evaluation visit must include the following:

* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;

* Integration of findings and recommendations at team conferences;

* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;

* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and

* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:

* relevant history;

* medical findings by specialty;

* problem areas that may develop and for which the beneficiary should receive care;

* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;

* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and

* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).

Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.


BASIC AND ONGOING COMPREHENSIVE EVALUATION

Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in  the CMDS POC.

A basic and ongoing comprehensive evaluation may include the following activities:


* Comprehensive beneficiary assessment;

* Evaluation and identification of the beneficiary’s needs;

* Coordination of the beneficiary’s multi-disciplinary needs;

* Review and modification of the comprehensive CMDS POC;

* Assured implementation and follow-up; and

* Referrals to other professionals, resources, and services as applicable.

Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.

Medical services continue to be billed as usual.

 MANAGEMENT/FOLLOW-UP VISITS

Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.



The management/follow-up visit may include:

* A physical exam by a pediatrician and/or physician subspecialist(s);

* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;

* Follow-up on all components identified in the CMDS POC by appropriate staff;

* Update of condition and treatment, and revision of the CMDS POC; and

* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.

Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


 SUPPORT SERVICE VISITS

CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.

* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.

* The clinical content of the encounter is documented in the CMDS POC.

CMDS support service visits include and provide two different methods of delivery:

* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or

* Telephone meetings between the appropriate clinic professional and the family/beneficiary.

Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


ADDITIONAL RESPONSIBILITIES

CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.

* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.

* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.

The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.

CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.

Explanation of Services


In addition to medical services, the CMDS Clinics provide:

• A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well other appropriate health care professionals during that one appointment;

• An environment where the providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;

• Same day, face-to-face care coordination by all of the providers who have seen the beneficiary at that appointment allows for immediate discussion, negotiation, coordination and duty assignment of the decisions made that resulted from the provider meeting that follows the appointment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual
service methodology;

• Development and upkeep of a coordinated and comprehensive plan of care and treatment for beneficiaries including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;

• Facilities that are tailored to the needs of children and their families; and

• Opportunity for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.


Friday, June 7, 2019

Medicare Diabetes Prevention Program (MDPP)


Expanded Model Fact Sheet Overview of MDPP

The MDPP expanded model includes an evidence-based set of services aimed to help prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. MDPP services will be available to eligible beneficiaries nationwide beginning April 1, 2018 under a performance-based payment model through the CMS Innovation Center.

Questions about MDPP

What is covered through the model?

• Structured sessions with a coach, using a CDC-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies

• 12 months of core sessions for beneficiaries with an indication of prediabetes, and an additional 12 months of ongoing maintenance sessions for participants who meet weight loss and attendance goals.

How does the model pay for MDPP services?

MDPP suppliers are paid performance-based payments through the CMS claims system. Medicare payments to suppliers will range, and can be up to $670 per beneficiary over
2 years, depending on beneficiaries’ attendance and weight loss.

What does this mean for beneficiaries?
Beginning April 1, 2018, eligible beneficiaries have coverage of MDPP services with no costsharing through Medicare-enrolled MDPP suppliers.
Eligible beneficiaries are those who:
• Are enrolled in Medicare Part B
• Have a body mass index (BMI) of at least 25, or at least 23 if self-identified as Asian
• Meet 1 of the following 3 blood test requirements within the 12 months of the first core session:
    ? A hemoglobin A1c test with a value between 5.7 and 6.4% , or
    ? A fasting plasma glucose of 110-125 mg/dL, or
    ? A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
• Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
• Do not have end-stage renal disease (ESRD)

What does this mean for providers?

Although a referral from a physician is not required for beneficiaries to participate in MDPP services, clinicians have an important role to play in helping beneficiaries understand their risk of diabetes and their treatment options. This is particularly important because only 14% of adults aged 65 and older with prediabetes are aware of their condition. Clinicians may help Medicare patients obtain the blood tests they need to become aware of their risk and recommend they
participate in MDPP services.

What does this mean for organizations that wish to deliver MDPP services?

Organizations who wish to furnish MDPP services to beneficiaries and bill Medicare for those services must enroll in Medicare as an MDPP supplier.

To enroll as an MDPP supplier, organizations must:
• Have MDPP preliminary recognition or full CDC DPRP recognition
• Have an active and valid tax-identification number (TIN) or national provider identifier (NPI)
• Pass enrollment screening at the high categorical risk level
• On the MDPP enrollment application, submit a list of MDPP coaches who will lead sessions,including full name, date of birth, social security number (SSN), and active and valid NPI and coach eligibility end date (if applicable)
• Meet MDPP supplier standards and requirements, and other requirements of existing Medicare providers or suppliers
• Revalidate its enrollment every 5 years

Key Dates
• January 2018– MDPP supplier enrollment begins
• April 2018– Enrolled MDPP suppliers may begin furnishing services and billing Medicare

Centers for Disease Control and Prevention.
CDC twenty four seven. Saving Lives, Protecting People

National Diabetes Prevention Program
CDC-recognized lifestyle change programs are based on years of research showing that a year-long, structured lifestyle change intervention reduced the incidence of diabetes by 58% among adults with prediabetes and by 71% among those aged 60 years or older. The same study showed a 31% reduction with metformin compared with placebo. The researchers concluded that the lifestyle intervention was significantly more effective than metformin.

And the results last. Even after 10 years, people who completed a diabetes prevention lifestyle change program had a 34% lower rate of type 2 diabetes.

Participating in a program to lose weight through healthy eating and increased physical activity can also reduce the risk of heart attack and stroke.

Quality Standard

To ensure high-quality interventions, CDC only recognizes lifestyle change programs that meet evidence-based standards and show they can achieve results. These standards include:

• Following a CDC-approved curriculum
• Facilitation by a trained lifestyle coach
• Making regular data submission (according to the timeline dictated in the current DPRP Standards) to show that the program is having an impact.

Serious & Common

More than 84 million US adults—that’s 1 in 3—have prediabetes. With prediabetes, blood sugar is higher than normal but not high enough yet to be diagnosed as diabetes. People with prediabetes are at high risk for type 2 diabetes (the most common type of diabetes), heart disease, and stroke.

In the last 20 years, the number of adults diagnosed with diabetes has more than tripled as the US population has aged and become more overweight. Now more than 30 million Americans have diabetes, which increases their risk for a long list of serious health problems, including:

•Heart attack
•Stroke
•Blindness
•Kidney failure
•Loss of toes, feet, or legs
The good news: the CDC-led National Diabetes Prevention Program’s lifestyle change program can help people with prediabetes prevent or delay type 2 diabetes and other serious health problems and improve their overall health. It’s scientifically proven, and it works.

Diabetes Is Expensive
Diabetes has an enormous economic impact on millions of individuals and their families, on workplaces, and on the US health care system.

In 2017, the total estimated cost of diagnosed diabetes was $327 billion ($237 billion in direct medical costs and $90 billion in lost productivity), up 26% over a 5-year period.
About 1 in 4 health care dollars is spent on people with diagnosed diabetes.
Medical expenses for people diagnosed with diabetes—$16,750 annually on average—are about 2.3 times higher than for people without diabetes.

The Time To Act Is Now
Don’t let the “pre” in prediabetes fool you—prediabetes is a serious health condition that can develop into even more serious health conditions.

Program Eligibility

CDC-recognized lifestyle change programs are designed for patients who have prediabetes and are at high risk for developing type 2 diabetes.

Follow the guidelines below to know which patients are eligible for the program.
Which Patients to Refer
To be eligible for referral to a CDC-recognized lifestyle change program, patients must meet the following requirements:

•Be at least 18 years old and
•Be overweight (body mass index =25; =23 if Asian) and
•Have no previous diagnosis of type 1 or type 2 diabetes and
•Have a blood test result in the prediabetes range within the past year:
    •Hemoglobin A1C: 5.7%–6.4% or
    •Fasting plasma glucose: 100–125 mg/dL or
    •Two-hour plasma glucose (after a 75 gm glucose load): 140–199 mg/dL or
•Be previously diagnosed with gestational diabetes


Prediabetes can be diagnosed via oral glucose tolerance tests, fasting blood glucose tests, or an A1C test. Blood-based testing is the most accurate way to determine if a patient has prediabetes.

Thursday, May 23, 2019

Does out of state patient eligible for coverage ?


COVERAGE OUT OF STATE



A member, who is temporarily out of the state but still a resident of Arizona, is entitled to receive AHCCCS benefits under any of the following conditions:

1. Medical services are required because of a medical emergency. Documentation of the emergency must be submitted with the claim to AHCCCS.

2. The member requires a particular treatment that can only be obtained in another state.

3. The member has a chronic illness necessitating treatment during a temporary absence from the state or the member’s condition must be stabilized before returning to the state. Services furnished to AHCCCS members outside of the United States are not covered.


 GENERAL QUESTIONS

* We have patients that come from other states and have Medicaid from other states. How do we handle this?


Florida Medicaid cannot be billed for Medicaid recipients from other states.  Each state’s Medicaid program operates independently essentially 50 separate programs).Florida Medicaid  beneficiaries are covered for emergency care or prior approved care in other states. You would have to contact the other state’s Medicaid program to find out if they have a similar provision for their beneficiaries who need out-of-state care.

TRANSPORTATION REQUIRING PRIOR APPROVAL

Non-Emergency Medical Transportation (NEMT)


- All requests for out-of-state transportation and certain related expenses must have prior approval from the broker, except for travel to those facilities which have been granted in-network status. Facilities granted innetwork status are considered in-state providers. Members are required to contact the broker to schedule the travel for all medical appointments or visits, regardless of the in-network or out-of-network status.

NOTE: Individuals who receive both Medicare and Medicaid do not require prior approval for out-of-state transportation


Hospital - An entity that is licensed as an acute care hospital in accordance with applicable state laws and regulations, or the applicable state laws and regulations of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term “hospital” includes a Medicare- or state-certified distinct rehabilitation unit, a “psychiatric hospital” as defined in this section, or any other distinct unit of the hospital. (WAC 182-550-1050)


Out-of-state hospital admissions (does not include hospitals in designated bordering cities)


The agency pays for emergency care at an out-of-state hospital for Medicaid and CHIP clients only.

Note: The agency considers hospitals in designated bordering cities, listed in WAC 182-501-0175, as in-state hospitals for coverage and as out-of-state hospitals for payment, except for critical border hospitals. The agency considers critical border hospitals “in-state” for both coverage and payment.

The agency requires PA for elective, non-emergency care. Providers should request PA when:

• The client is on a medical program that pays for out-of-state coverage. Example: Aged, Blind, Disabled (ABD) Assistance (formerly Disability Lifeline clients) have no out-ofstate benefit except in designated bordering cities.




ELIGIBILITY EFFECTIVE DATES

The following general guidelines apply to eligibility effective dates:

1. For most members, eligibility is effective from the first day of the month of application, the first day of the month in which the member meets the qualifications for the program, or their date of birth, whichever is later.

2. For KidsCare members, if the eligibility determination is completed by the 25th day of the month, eligibility begins on the first day of the following month. For eligibility determinations completed after the 25th day of the month, eligibility begins on the first day of the second month following the determination of eligibility.

3. For Medicare Savings Program (MSP) – QMB members, eligibility begins with the month following the month that QMB eligibility is determined.

4. For Breast and Cervical Cancer Treatment Program (BCCTP) members, eligibility begins on the later of the first date of the month (the application month for BCCTP is the month of the BCCTP diagnosis), or the first day of the month in which the customer meets all the BCCCTP eligibility requirements.

5. For a move into state or release from prison, the begin date is no sooner than that date.

Thursday, May 2, 2019

CPT code 99231, 99232. 99233 - Medical necessity tips

Define Medical necessity:


Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

Practice that is reporting a higher number of these 99233 and 99214 codes than their peers may
substantially increase their risk of audit and review. the CERT study gives the opportunity identify potential errors the same way that the auditor's do.


This article focuses on the most common coding errors identified in the report to help you understand how to prevent them from occurring at your practice.

The key point to using 99233 is the provider must be sure to meet two of the three components:
• Detailed interval history
• Detailed examination
• High complexity Medical decision making (MDM)

Alternatively, they could spend 35 minutes or more of face-to-face time with the patient. Comorbidities and other underlying diseases cannot be considered when selecting 99233 unless their presence significantly increases the complexity of the medical decision making. Also if the provider chooses to use time to base the assignment of 99233, the time must be documented in the patient’s medical record and the documentation must have sufficient detail to justify the code selection.


Documentation Tips:

1. Documentation must be entered in a timely manner and must be decipherable to members of the healthcare team as well as other individuals who may need to review the information (e.g., auditors). Proper credit cannot be given for documentation that is difficult to read.

2.Information should include historical review of past/interim events, a physical exam, medical decision-making as related to the patient’s progress/response to intervention, and modification of the care plan (as necessary). The reason for the encounter should be evident to support the medical necessity of the service. Because various specialists may participate in patient care, documentation for each provider’s encounter should demonstrate personalized and non-duplicative care.


3.Each individual provider must exhibit a personal contribution to the case to prevent payors from viewing the documentation as overlapping and indistinguishable from care already provided by another physician. Each entry should be dated and signed with a legible identifier (i.e., signature with a printed name).


Consider Patient's condition:

Neither guidelines provide fully objective, quantitative criteria by which medical necessity for an E/M Service may be judged. Understanding the medical necessity for ordering a lab or radiologic exam is comparatively easy:

Example: A provider orders a chest x-ray for suspected pneumonia, or serial troponins are ordered for chest pain to rule out acute coronary syndrome. Connecting the dots between a 99233 and medical necessity is not as clear.

Fortunately, CPT provides a clue in the full descriptor for CPT 99233. Usually, the patient is unstable or has developed a significant complication or new problem.

''Usually'' statement referencing the stability of the patient
• 99231 “Usually, the patient is stable, recovering or improving.”
• 99232 “Usually, the patient is responding inadequately to therapy or has developed a minor complication.”
• 99233 “Usually, the patient is unstable or has developed a significant complication or a significant new problem
Based on these statements, it is the documented stability of the patient that determines the medical necessity of these subsequent care levels (when not billing based on time)



Differentiate between ''Significant'' and ''Unstable'':

''Significant'' and ''Unstable'' these terms are not specifically defined, we can use Medicare's 1995 and 1997 Documentation guidelines for E/M services to point us in the right direction—Specifically, the examples for a high level of risk under the presenting problem in the table of risk:
• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment.
• Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure.
• An abrupt change in neurologic status, e.g., seizure, TIA, weakness, sensory loss.

For a new complication or problem to be considered “Significant” it should be comparable to the table of risk examples.

''Unstable'' also follows this guideline, but for ongoing conditions rather than new problems or complications.
CPT CODE 99231, 99232, 99233, 99291 - PATIENT STABILITY

Example: A patient admitted yesterday for sepsis with respiratory failure and acute kidney injury, who today remains presents tachypnea and tachycardic, with worsening oxygen requirements and significantly elevated blood urea nitrogen (BUN), creatinine and lactate levels. Accounting for the presenting problems and the usually statements in the CPT and factoring in critical care, you can create a spectrum of patient stability that points to the medical necessity requirements for each subsequent care code level, as shown mentioned below table.







One condition documented as ''Improving'' does not mean the patients overall condition is stable.


Time-based coding changes the Criteria:

The physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided.

Documentation must be in sufficient detail to support the claim:

Physicians must document both the counseling/coordination of care time and total visit time. The format may vary: “Total visit time = 35 minutes; more than 50% spent counseling/coordinating care,” or “30 of 35 minutes spent counseling/coordinating care.” Any given payer may prefer one documentation style over another. It always is best to query payers and review their documentation standards to determine the local preference.


In addition to the time, physicians must document the medical decision-making and details of the counseling/coordination of care. For example, patients with newly diagnosed diabetes need to be educated about their condition, lifestyle, and medication requirements. Physicians should include information regarding these factors in their progress notes as necessary.

Note:

The Centers for Medicare and Medicaid Services (CMS) released the results from their Comprehensive Error Rate Testing (CERT) earlier this year. The results showed a 9.5% overall improper payment rate for 2017, representing $36.21 billion in improper payments.

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