NE MGMA conference, May 6, 2016
Who cares about coding?
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Fee for service revenue driven by CPT
Physician work valued by wRVUs assigned to
codes
If capitation, measurement back to ffs revenue
Diagnosis coding (along with quality, cost,
satisfaction and other measures) may result in
payment adjustments
©2016 Betsy Nicoletti
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Non-fee-for-service revenue:
2014
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Generously shared by David Gans,
MGMA, via email
Working towards the “Triple Aim”
 Primary care: a small fraction had capitation,
small revenue
 Multi-specialty groups: ¼ of the groups
reported capitation revenue, 7% of total
revenue
Adding ACO revenue: 4% for private
practices, 7% for hospital
owned
practices
©2016 Betsy
Nicoletti
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Project agenda
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E/M compliance
audit
Diagnosis coding
and risk
adjustment—prior to
ICD-10
implementation
IM and FP groups in
different locations,
hospital employed
But first:
Review CPT
frequency for each
provider
Frank Cohen sent
me list of CMS data,
CPT codes, by
volume
©2016 Betsy Nicoletti
Startling variance in top 25 CPT
codes
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E/M measure to track
Frequency/variance of reporting high RVU
valued services
Compliance issues raised based solely on
CPT report
Diagnosis coding prior to ICD-10
implementation—didn’t support risk
adjustment
©2016 Betsy Nicoletti
Single metric
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One predictor of revenue and wRVU
Significant variation from CMS norm by
provider, by practice sites
Confounded by incorrectly assigning nurse
visits in a practice
99214s as a percentage of total
established patient visits
©2016 Betsy Nicoletti
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CMS norms—established
patients
©2016 Betsy Nicoletti
IM/FP E/M established patients
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CMS data
©2016 Betsy Nicoletti
CMS data
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Patients over 65 or disabled
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Family Practice with a lot of kids will
have a different profile
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A provider assigned to walk in—may lower
profile
Nurse visits assigned all to one clinician
confound the data
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©2016 Betsy Nicoletti
99214 As Percent of Established Patients
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High Coders
Low Coders
©2016 Betsy Nicoletti
Inaccurately assigned nurse visits
confounds % of 99214 metric
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©2016 Betsy Nicoletti
Ratio of 99213 to 99214
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Many clinicians
with more
99213s than
the CMS norm
©2016 Betsy Nicoletti
3rd metric: wRVU per encouter
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MGMA Family Practice: wRVUs 4904,
Encounters 3519 = 1.39
Causes of variation in this metric:
 Level of service
 High RVU valued services wellness visits
transitional care management and split visits
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©2016 Betsy Nicoletti
Unusually high volume of 99212
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FP05 22% 99212 visits
Incorrectly reporting an E/M service with a
procedure
Compliance issue
This requires documentation review to
discover if under-coding A LOT or if the E/M
was not a reportable service
©2016 Betsy Nicoletti
Transitional Care Management
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Requires system in place in practice for phone
call after discharge, visit scheduling, case
management
System needed to hold billing until day 30
(changed by CMS as of 1.1.16)
Any specialty physician, PA or NP may
perform
©2016 Betsy Nicoletti
Transitional Care Management
(TCM)
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Comparing established patient visits with TCM
©2016 Betsy Nicoletti
TCM by Family Practices
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TCM by IM Practices
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TCM by Volume for One Practice
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TCM Volume by Provider
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Revenue Opportunity: TCM
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• Assume 120 TCM visits and 120 fewer 99214s
• $6,800 Revenue Opportunity per Provider
TCM
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If not billing, most
physicians and
NPPs are doing the
post discharge work
This is an easy
revenue pick up
©2016 Betsy Nicoletti
Wellness visits
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©2016 Betsy Nicoletti
Wellness Visits by Family Practice
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Wellness Visits by IM Practice
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Revenue Opportunity: Wellness Visits
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• Assume 300 Wellness visits and 300 fewer 99214s—
CONSERVATIVE assumption. Many providers do both at one visit.
• $13,000 Revenue Opportunity per Provider
Why is $13,000 conservative?
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Wellness and problem oriented visit may be
performed on the same day
Often both are documented
Providers: all or nothing
©2016 Betsy Nicoletti
Other revenue opportunities
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Chronic care management, effective 1-1-15
This service requires case management, software
support
Modern Healthcare article 10/17/15: 35 million
eligible beneficiaries, only 100,000 billed
Many barriers to providing and reporting
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Advance care planning, effective 1-1-16
Modest payment for discussion of advance
directives
©2016 Betsy Nicoletti
Orphan procedures
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©2016 Betsy Nicoletti
Lab billing, based on CMS fees
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Practices do only CLIA waived tests
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Lowest lab biller: $220.93
Highest lab biller: $5,341.35
Average: $1,182.93
Suspect: missed charges
Charges reported under wrong provider
©2016 Betsy Nicoletti
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You don’t have to pull a single
chart
©2016 Betsy Nicoletti
Nurse Visit Variation
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Compliance & coding issues
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Nurse visits in some practices “assigned” to
one provider
Nurse visits are incident to services, and
should be reported by supervising clinician
(physician or NPP)
CMS clarified and confirmed this in 2016 Final
Rule
©2016 Betsy Nicoletti
Compliance & coding issues
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New patient visits: many providers had a
favorite—all billed at this level
This is a revenue or compliance issue
Volume usually small
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Two providers reported TCM all at the highest
level
Vaccines/injections billed with no
administration code
©2016 Betsy Nicoletti
Compliance & coding issues
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PTINR and finger stick billed: finger stick
always bundled
Finger stick billed with no lab test
Nebulizer treatment with no medications
©2016 Betsy Nicoletti
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Diagnosis coding—risk
adjustment
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Requires chart review, comparison with
Hierarchical Condition Categories (HCC) list of
diagnosis codes that risk adjust
Commercial payers may/may not share
proprietary list of codes that risk adjust
Providers selecting codes in EMR--”just need
to get out of this field.”
©2016 Betsy Nicoletti
Diagnosis coding—findings
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Review of documentation and ICD-9 codes in
preparation for ICD-10, risk adjustment
In some cases, unspecified codes selected, a
coder could not have selected a more specific
code from documentation
In some cases, unspecified codes selected, a
more specific code supported by
documentation
©2016 Betsy Nicoletti
Diagnosis coding
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Chronic conditions, with/without
manifestations, or without complications/with
complications
Trio: hypertension, heart failure, chronic kidney
disease: never correctly coded
Mental health diagnoses always selected with
a less specific code, when more specific codes
risk adjust
Depression, addiction
©2016 Betsy Nicoletti
Diagnosis coding
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Chronic conditions, with/without
manifestations, or without complications/with
complications
One message to providers: if a patient has a
diagnosis described by “with” manifestation or
complication:
USE IT!
©2016 Betsy Nicoletti
Diagnosis coding—report yearly
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Status codes often
missed
Risk categories:
significant, chronic
illnesses
Chronic illnesses with
complications
©2016 Betsy Nicoletti
Next steps
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Run CPT frequency
Select E/M metric
and report to
providers monthly
Review variation in
TCM, wellness visits
Review frequency of
wellness visits and
problem oriented
visits
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Add TCM and
wellness visit
practice support
Review charging for
nurse visits
Identify unusual
99212, 99214 %
Look for favorite
new patient coding
©2016 Betsy Nicoletti
Next steps
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Investigate lab
variance
Injections/immunizat
ions—administration
codes
Review of split visits
Coding review in
support of
revenue—not just
compliance
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Diagnosis coding
support for risk
based
Pulmonary services:
nebulizer, instruction
©2016 Betsy Nicoletti
Best use of coders
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Diagnosis coding for risk adjustment
Review split visits
Ancillary services coding
99212 visits
Significant outliers—not every E/M service
©2016 Betsy Nicoletti
Waiting for Triple Aim
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But revenue and
measure of physician
work still based on
coding
©2016 Betsy Nicoletti
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Betsy Nicoletti
www.betsynicoletti.com
www.codapedia.com
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[email protected]
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Follow me on twitter
@BetsyNicoletti
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©2016 Betsy Nicoletti