6/1/2011How to Teach Your Physician E/M:Part I: How to PrepareKerin Draak, MS, WHNP-BC,CPC, CPC-I, CEMC, COBGC1Purpose Tips Techniques Strategies21

6/1/2011Do Your Homework Know your audience– Experience– Preferences– Attitude– Learning style Visual Auditory Kinesthetic or tactile3Background E/M guidelines introduced in 1994 Some practicing providers were educatedprior to introduction of DocumentationGuidelines Purpose of medical record has evolved– Paper Electronic– Provider-to-provider communication42

6/1/2011Reason for E/M Education Varied reasons for teaching E/M– Compliance– Financial– Fear– Voluntary5Needs of the Participants Educator– Time expectations– Work involved– Attitude Provider– Time expectations– Work involved– Attitude63

6/1/2011Tools Purchased learning tools Customized learning tools Authoritative sources– CMS LocalNationalDocumentation GuidelinesNCCI– AMA7Tools Purchased– Reliable and creditable source vs. opinion Google Wikipedia– Outside consultant– Software– Seminars, webinars, conferences84

6/1/2011Educational Tools Customized– Flexible– Meet needs of compliance plan– Consistency– Individualized Specialty Primary care9Tools Authoritative– CMS overview.asp#TopOfPage– Chapt 1, General Correct Coding Policies– IOM, 100-04, Chapter 12, Section 30.6105

6/1/2011Stay Up-to-Date with CMS asp#TopOfPage11CMS Transmittal Example6

6/1/2011Medicare Learning Network13MLN Matters Article ExampleMLN Matters Number: MM6740 RevisedRelated Change Request (CR) #: 6740Related CR Release Date: December 14, 2009Effective Date: January 1, 2010Related CR Transmittal #: R1875CPImplementation Date: January 4, 2010Revisions to Consultation Services Payment Policy147

6/1/2011MLN Matters Article ExampleNCCI ExampleCh 1, Sect D. Evaluation andManagement (E&M) Services„If a procedure has a global period of 000 or 010 days, it is defined as aminor surgical procedure. The decision to perform a minor surgicalprocedure is included in the payment for the minor surgical procedureand should not be reported separately as an E&M service. However, asignificant and separately identifiable E&M service unrelated to thedecision to perform the minor surgical procedure is separatelyreportable with modifier 25. The E&M service and minor surgicalprocedure do not require different diagnoses. If a minor surgicalprocedure is performed on a new patient, the same rules for reportingE&M services apply. The fact that the patient is “new” to the provider isnot sufficient alone to justify reporting an E&M service on the same dateof service as a minor surgical procedure.‟168

6/1/2011Comprehensive Error Rate Testing Established to determine national paid claimserror rate MACs are audited to determine properpayment and denials Provider documentation reviewed todetermine if paid services meet the coverageguidelines and coding and documentationguidelines17Comprehensive Error Rate Report.pdf189

6/1/2011Medicare Administrative Contractors Cahaba GBA: Alabama, Georgia, Mississippi, andTennessee. Cigna Government Services: Idaho and m/ First Coast Service Options: Florida Administrative Contractors Highmark Medicare Services: Delaware, District ofColumbia, Maryland, New Jersey, and om/ National Government Services: Connecticut, Indiana,Kentucky, and New York NHIC Corp: Maine, Massachusetts, New Hampshire,Rhode Island, and Vermont

6/1/2011Medicare Administrative Contractors Noridian Administrative Services: Alaska, Arizona,Montana, North Dakota, Oregon, South Dakota, Utah,Washington, and Wyoming Palmetto GBA: California, Hawaii, Nevada, Ohio, SouthCarolina, and West to.nsf/DocsCat/Home Pinnacle Business Solutions: Arkansas and e Administrative Contractors Trailblazer Health Enterprise: Colorado, New Mexico,Oklahoma, Texas, and Virginia WPS (Wisconsin Physicians Service) InsuranceCorporation: Illinois, Iowa, Kansas, Michigan,Minnesota, Missouri, Nebraska, and Wisconsin

6/1/2011Medicare Claims ProcessingManual Example40.1 - Definition of a Global Surgical PackageB. Services Not Included in the Global SurgicalPackage“Carriers do not include the services listed below in the paymentamount for a procedure with the appropriate indicator in Field 16 of theMFSDB. These services may be paid for separately. The initialconsultation or evaluation of the problem by the surgeon to determinethe need for surgery. Please note that this policy only applies to majorsurgical procedures. The initial evaluation is always included in theallowance for a minor surgical procedure.”23Medicare Claims ProcessingManual Example100 - Teaching Physician ServicesStudent - An individual who participates in an accreditededucational program (e.g., a medical school) that is not anapproved GME program. A student is never considered tobe an intern or a resident. Medicare does not pay for anyservice furnished by a student.2412

6/1/2011Medicare Claims ProcessingManual Example60.1 - Incident To Physician’s Professional ServicesB - Direct Personal Supervision“Direct supervision in the office setting does not mean that thephysician must be present in the same room with his or her aide.However, the physician must be present in the office suite andimmediately available to provide assistance and directionthroughout the time the aide is performing services.”25Tools American Medical Association– CPT is registered trademark of theAmerican Medical Association13

6/1/2011Educational Tools Organize handouts/reference material– User friendly format– Simple and concise– Customize to specialty– Avoid wrongful assumptions27Educational ToolsHistory Chief Complaint (CC)– Who can obtain and document History of Present Illness (HPI)– Who can obtain and document– Can one element be counted more than once– 1997 DG for chronic conditions Review of Systems (ROS)– What is acceptable documentation Past Medical, Family & Social History (PFSH)2814

6/1/2011Educational ToolsHistory History unobtainable– Document why– What level of history when unobtainable29Educational ToolsExamination 1995 vs. 1997 Documentation Guidelines– Descriptions needed if using 1995 Extent of examination– Provider discretion3015

6/1/2011Educational ToolsMedical Decision Making Definitions– Additional work-up– New problem– Independent review– Summarization of records31Medicare Claims Manual Chapt. 13100.1 - X-rays and EKGs Furnished to EmergencyRoom Patients“Carriers generally distinguish between an “interpretation and report” of anX-ray or an EKG procedure and a “review” of the procedure. A professionalcomponent billing based on a review of the findings of these procedures,without a complete, written report similar to that which would be prepared by aspecialist in the field, does not meet the conditions for separate payment of theservice. This is because the review is already included in the emergencydepartment evaluation and management (E/M) payment. For example, anotation in the medical records saying “fx-tibia” or EKG-normal would notsuffice as a separately payable interpretation and report of the procedure andshould be considered a review of the findings payable through the E/M code.”3216

6/1/2011Audit Tools Consistent– Implementation– Definitions– Format33Meeting Time Schedule meeting date/time– Be specific with time constraints– Patient care time vs. personal time Confirm meeting date/time– Confirm, do not remind Language– Non-verbals carry via phones/emails– Polite and professional3417

6/1/2011Communication Skills Active listening Paraphrasing– Restating a message, but usually with fewer words Summarizing– Pulling together, organizing, and integrating the majoraspects of your dialogue Primary empathy– Reflection of content and feelings35Resistance to Change When the reason for the change is unclear. When the proposed users have not been consultedabout the change, and it is offered to them as anaccomplished fact. When the change threatens to modify establishedpatterns of work flow or processes. When communication about the change--timetables,personnel, monies, etc.--has not been sufficient. When the benefits and rewards for making the changeare not seen as adequate for the trouble involved.3618

6/1/2011Back-up Plan How to handle a difficult provider– Keep your cool– Keep the tone of your voice pleasant– Think and then don‟t speak– Don‟t become defensive– Don‟t accept being bullied37Thank You3819

6/1/2011 8 MLN Matters Article Example 16 NCCI Example Ch 1, Sect D. Evaluation and Management (E