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Building Blocks of Developmental Screening

 
 

By: Melanie Thelian CPC, CPC-I
Medco Consultants, Inc
 

CPT 96110 Developmental Screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument, is a commonly used code in the pediatric setting. The work and time provided by the treating provider identifies the development of the growing child. Because this service is recommended by the American Academy of Pediatrics (AAP) in providing quality preventive medicine, many physicians and/or other qualified healthcare professionals are oftentimes confused on how to document the service.

With an increasing number of commercial insurance carrier audits, requesting refunds for insufficient documentation of CPT 96110, it is important to document the full description of the code. The description of the code includes “instruments and scoring”. However, to date there is no official standardized instrument nationally recognized. 

Follow these documentation requirements when providing the screening to avoid potential overpayment requests:

  • Q&A on age appropriate growing an development (I.e Ages and Stages; Mchat)
  • Scoring by the physicians and/or other qualified healthcare professionals
  • A brief interpretation by the treating provider
  • The treating provider should sign and date the instrument utilized and scan/ save in the patient’s file/chart.
     

Sources:
American Medical Association Current Procedural Terminology Manual (CPT) 2017

CPT Changes, 2008, Preventive Medicine Services Counseling Risk Factor Reduction and Behavior Change Intervention

Coding and Billing Chronic Lyme Disease

 
 

By: Lorna Simons, CPC
Medco Consultants, Inc
 

May was Lyme Disease awareness month during which celebrities such as Kelly Osbourne and Alec Baldwin described their personal stories with the disease. Though May is over, Lyme disease season continues as we get ready for the summer months.

The Centers for Disease Control (CDC) and National Institute of Allergy and Infectious Disease (NIAID) currently recommend a 2- 4 week course of oral antibiotics for treatment of Lyme disease. Many insurance carriers follow this guidance when it comes to treating the illness. This can be difficult when it comes to billing patients with continuing Lyme symptoms beyond that initial period for treatment.

The term “Chronic Lyme Disease” is a misnomer, instead the CDC and NIAID recognize Post-Treatment Lyme Disease Syndrome (PTLDS). Experts believe the symptoms of PTLDS may be caused by tissue and immune system damage caused by the Lyme disease. 

There currently is no ICD-10-CM code for PTLDS (or Chronic Lyme Disease). In the ICD-10-CM manual, Lyme disease is a subcategory with additional subdivisions. For ICD-10-CM coding of PTLDS, it would be appropriate to choose the subdivision code that most accurately describes the patient’s symptoms.

There is no current standard for treating PTLDS due to continuing disagreement in the medical community. If a patient presents with Lyme symptoms after the standard course of treatment, it is advisable to check their insurers policy for any treatment limitations. It may be necessary to provide the patient with an Advanced Beneficiary Notice (ABN) as some carriers see the treating of PTLDS with long-term antibiotics as experimental.

Understanding Modifier 24

 
 

Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period) is used when a provider performs a separately identifiable service during a patient’s post-op period. 

These services are not related to the procedure previously performed. Remember the following when using Modifier 24:

  • This modifier is used only with E/M services.
  • It is used when the E/M service provided is unrelated to the original procedure  
  • It is used when the E/M service is provided by the same physician who previously performed the original procedure on the patient
  • It is used when the E/M service is provided during the postoperative period of the procedure
  • This modifier does not increase or decrease reimbursement. It does get the E/M service reimbursed. (Bypass edits in carrier’s software systems)

If the patient presents with a complication requiring treatment, such as bleeding or infection due to the procedure, it would be inappropriate to append the modifier. 

Also remember that postoperative periods can vary from carrier to carrier and can be anywhere from 10- 90 days. Follow up visits performed outside of the global period should be coded with the appropriate E/M.

CMS to Share Physician MIPS Scores With The Public

 
 

If you were thinking of reporting the minimal amount of MIPS data to avoid a payment reduction, you might want to think again.

It has been well known that CMS publishes comparative physician data on their website (data.medicare.gov). This data in in an excel format and allows you to compare your utilization with your peers. 

You MIPS data is similar to a report card and CMS will make this data available to the public on the following sites, Physician Compare, Yelp, Consumer reports and Google. The database will include individual physician names.

Publishing this data can impact the physician in a number of ways:

  • Physicians looking to join new groups or selling their practice will more than likely have their scores reviewed
  • Physicians who are providing excellent quality of care for their patients but elect to report only the minimum amount of data will have a lower score available to the public. This could potentially reduce the number of new patients to the practice. 

It is important to keep in mind unreported measures and categories can be seen as poor performance by those who are seeking the physician’s score. 

Understanding the Medicare IPPE and Annual Wellness Visits

 
 

There is a lot of confusion when it comes to the Medicare Initial Preventive Physical Examination (IPPE) and Annual Wellness Visits (AWV). Many providers document the IPPE and Annual wellness similarly to a yearly physical exam. These services are not comprehensive physicals and require a minimal physical exam. Instead, they are a tool to assess and promote the patient’s overall health and well-being. The IPPE and Annual wellness exams have different criteria. Receiving an IPPE exam does not preclude the patient from receiving an initial annual wellness.


The IPPE (G0402), commonly known as the Welcome to Medicare Visit, is eligible for new Medicare participants within their first 12 months in the Medicare plan. Medicare recommends contacting your local MAC prior to the visit to ensure the patient is eligible for the service. 
The Initial AWV (G0438) is a more comprehensive visit. It is available for patients a year (at least 11 months) after their IPPE OR if the patient is no longer within the eligibility period for the IPPE. The Subsequent AWV (G0439) is an update of information received at the initial AWV. 

Below is a comparison of the documentation to support each service. The items needed for both services are italicized and bold.

IPPE (G0402)

  • A review of the patients medical and social history
  • A review of any potential risk factors for depression/ mood disorders
  • A review of the patient’s functional abilities (i.e. Hearing, ADLs, fall risk, etc.)
  • A physical exam including vitals, vision acuity and any factors of concern based on the patient’s medical and social history (i.e. if the patient has cardiovascular disease the provider may examine the extremities for vascular symptoms and the heart)
  • End-of-life planning
  • Education, counseling and referrals based on the patient’s history, risk factors, functional ability and exam
  • Treatment plan including referrals for other age based preventative services
 

Initial AWV(G0438)

  • A Health Risk Assessment 
  • List of current providers and suppliers (If you are currently the patient’s only healthcare provider, that should be noted)
  • A review of the patients medical and family history
  • A review of any potential risk factors for depression/ mood disorders
  • A review of the patient’s functional abilities (i.e. Hearing, ADLs, fall risk, etc.)
  • A physical exam including vitals, and any factors of concern based on the patient’s medical and family history (i.e. if the patient’s mother had skin cancer, the provider may check for irregular moles)
  • Assessment of cognitive function
  • Creation of an age relevant screening schedule 
  • Establish a list of risk factors and any current/recommended interventions
  • Advice and counseling to reduce health risks and promote wellness

It is important to note the extent of the physical examination performed is based on the patient’s medical history and either the social or family history for the IPPE and AWV. No specific diagnosis is recommended for reporting these evaluations. 


Prior to these visits, it is recommended to contact the patient and/or caregiver to encourage them to bring in personal medical records, family history and a list of their current medications/ vitamins when they present for their visit. 

 

Advanced Beneficiary Notice Refresher

 
 

With the new Advanced Beneficiary Notice (ABN) coming into effect on June 21, 2017, it is a wonderful time to give a refresher on the proper way to fill out the form. ABNs are provided to educate the patient on an item/service that may not be covered by Medicare but may aid in the patient’s treatment. The ABN, when filled out properly, lets the patient know what the item / service is, when and by whom the item/service will be given /performed and the potential cost of the service. With all of the information provided, the patient can decide whether or not to have the item/service and sill sign the notice. It is important to remember without a properly filled out written notice, the patient is not financially liable if Medicare denies the item/service.


All the blanks / boxes on the form should be filled out completely. Remember to use the full names of the Notifier (supplier/treating physician) and patient. The complete item/service that will be given/performed should be entered into box “D”. For example: if the patient is going to be given physical therapy (PT) rather than writing just “physical therapy” the actual PT modalities should be noted. In Box “E” state why the service may not be paid. The estimated cost is necessary for the patient to know how much the treatment may cost if it is not covered by Medicare. Per Medicare, the estimate should be reasonable for all items/services noted. The cost should be within $100 or 25% of the fee for the item/ service. Always makes sure the patient marks the option they are choosing and the notice is signed in cursive and dated (including month, day and year).

Avoiding Obesity Counseling Denials

 
 

In 2015 Obesity Counseling G codes (G0447 Face-to-face behavioral counseling for obesity, 15 minutes and G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes) were reported 240,913 times but were denied approximately 80% of the time.

There are a few key points to consider when providing and documenting for these services. First and foremost is the type of provider. The National Coverage Determination (NCD) requires the services are provided by a qualified primary care physician or other primary care practitioner in a primary care setting. The counseling can be provided by qualified auxiliary staff (e.g. dietitian) under the direct supervision of a primary care provider. Secondly these codes have a frequency limitation. • One face-to-face visit every week for the first month; • One face-to-face visit every other week for months 2-6; and • One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.

Medlearn Matters MM7641 clearly defines the types of providers designated as primary care providers, frequency of services, and supporting diagnosis codes.

For more information on how to get it right click the following link: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7641.pdf

Radiology Audits

 
 

Recently insurance carriers have been auditing radiology services. Some of the areas being audited you may not have even given thought to checking. For example, do the images include the initials of the technician who performed the service? Without this information, the carriers can deny the claim until the technician has been identified and their credentials verified indicting they have the required certification to perform the service.


Insurance carriers are also verifying the orders with the ordering provider to make sure the medical necessity for ordering the test is documented. In some cases, the insurance carrier is leaving that responsibility up to the servicing provider. 


The source document frequently referenced by the carriers is the DOH Medicaid Update May 2006 Vol.21, No 5, Documentation Requirements for Ordered Services. Check it out https://www.health.ny.gov/health_care/medicaid/program/update/2006/may2006.htm


These are just two of the audit areas currently under review.

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