Io!
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Medicare Payment Policy
•  “Our first goal is for 30% of all Medicare provider
payments to be in alternative payment models that
are tied to how well providers care for their patients,
instead of how much care they provide…”
•  “Our second goal is for virtually all Medicare feefor-service payments to be tied to quality and value;
at least 85% in 2016 and 90% in 2018.”
–  Sylvia Mathews Burwell, HHS Secretary
2
Value-Based Payment Modifier
(a budget neutral program)
NOTE: * Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in th
of all beneficiary risk scores
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3 Step Process
1.  Patients are assigned to providers based on the
“plurality” of primary care:
1. 
2. 
3. 
4. 
5. 
New patient visits (99201 – 99205)
Established patient visits (99211 – 99215)
Home care (99341 – 99350) – not common
Annual wellness (G0438 & G0439) – 1 x per year at most
Welcome to Medicare (G0402) – 1 x per patient
2.  Quantify the quality & cost of care
3.  Adjust compensation based on the relationship
between quality and cost
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Quality Measures
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Hospital Inpatient Quality Reporting (IQR)
Hospital Outpatient Quality Reporting (OQR)
Medicare Shared Savings Program
Bundled Payment Model (episodes of care – bypass & hip
replacement)
Hierarchal Condition Categories (risk via ICD-10 codes)
Physician Compare: www.medicare.gov/physiciancompare
Quality Resource Use Reports (QRUR)
Physician Quality Reporting System (PQRS)
Electronic Health Record Meaningful Use
Value-Based Payment Modifier (ending in 2018)
Merit Based Incentive Payment System (MIPS) 2019
–  Existing and new quality measures rolled up into a single calculation
–  9% bonus or penalty based on the value & cost of care
•  20% variance between top and bottom performers
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Personal Shopper: Cost, Value, Quality
•  The primary care provider will be
accountable for the total cost of
patient care:
– 
– 
– 
– 
– 
– 
Medications
Diagnostic tests
Procedures
Devices
Facility expenses
Consultants
•  Added weight for: CHF, CAD, COPD,
& diabetes (bigger bonus/penalty)
•  Improve quality, reduce cost…
•  Evidence Based Care!
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Hospital Readmissions
•  20% of discharged Medicare patients are
readmitted within 30 days
Rehospitalizations among patients in the Medicare fee-for-service program.
New England Journal of Medicine 2009
•  The top complaint patients have associated with
hospitalization is continuity and transitions.
Quality of Health Care in the United States: A Chartbook.
The Commonwealth Fund
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Transitional Care Management
•  99495 – “Transitional Care Management Services with the
following required elements: Communication (direct contact,
telephone, electronic) with the patient and/or caregiver within
2 business days of discharge Medical decision making of at
least moderate complexity during the service period Face-toface visit, within 14 calendar days of discharge” ($165)
•  99496 – “Transitional Care Management Services with the
following required elements: Communication (direct contact,
telephone, electronic) with the patient and/or caregiver within
2 business days of discharge Medical decision making of high
complexity during the service period Face-to-face visit, within
7 calendar days of discharge” ($233)
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Standard PCP Patient Panel: hours/week
GuidelineRecommenda=ons
Acute
Chronic
Preven==ve
AverageFamilyPhysician
0
20
40
60
80 100 120
h@p://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm
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Chronic Care Management
•  Code 99490 ($41/month) is used to report this service.
The code’s definition is presented below. It describes the
service and illustrates which patients qualify:
–  “Chronic care management services, at least 20 minutes of
clinical staff time directed by a physician or other qualified
health care professional, per calendar month, with the
following required elements:
•  multiple (two or more) chronic conditions expected to last at least 12
months, or until the death of the patient,
•  chronic conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline,
•  comprehensive care plan established, implemented, revised, or
monitored.”
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The Other Side of the Bonus Calculation
•  Cost & Quality will dictate the percentage
amount used to calculate a bonus.
•  The bonus percentage will be applied to the
physician’s annual fee-for-service revenue.
–  9% of a large FFS pool vs.
–  9% of a small FFS pool
•  In addition to focusing on cost and quality, a
physician needs to bolster his/her FFS pool
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Service Level Selection
•  Medicare and other payers dedicate massive
resources to audit and prosecute over coding.
–  Penalties & refunds can be huge
–  Pre-payment reviews cripple cash flow
–  Providers can be sanctioned from govt. programs
•  Many providers have been intimidated into
routinely reporting lower service levels
–  Less FFS revenue now & a smaller FFS bonus pool
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2016 National Fee-For-Service M/C Rates
Est. Office Visits
F/U Hospital Visits
$146
4
4
$105
$109
3
3
$73
$73
2
2
$44
1
0
1
$20
$40
0
99211 99212 99213 99214 99215
99231
99232
99233
2 of 3 components must be met or exceeded for these visit categories.
History
Exam
Complexity
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New Patients and
Admits require all 3.
Follow-up Visits
require just 2 of 3
History
HPI
ROS
Levelof
Service
Exam
MFSHx.
Problems
Complexity
Data
Risk
All 3 History
variables are
required for
each type of
service.
Only 2 of 3
complexity
variables
required for
any type of
service.
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Chief Complaint: DGs
•  “The CC is a concise statement describing the
symptom, problem, condition, diagnosis, physician
recommended return, or other factor that is the
reason for the encounter.”
•  “The medical record should clearly reflect the chief
complaint.”
•  “A chief complaint is indicated at all levels.”
–  All four levels of history
•  “The CC, ROS and PFSH may be listed as separate
elements of history, or they may be included in the
description of the history of the present illness.”
E&M Documentation Guidelines
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History of Present Illness
•  Each element can only be credited once
•  HPI must be obtained fresh at each visit, it cannot be
carried over from one visit to the next
•  HPI must be obtained and documented by the billing
provider (not RN, MA, or questionnaire)
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Positive & Negative HPI Elements
CMS Official
•  Question:
–  The doctor might say "the patient's chief compliant is shortness of breath
which is not exacerbated with any specific activity and has no reported
associated symptoms."
–  The question is... should the doctor receive credit for documenting the HPI
element of modifying factors (since he said it is not exacerbated by any
activity) and associated signs/symptoms (since he said there are none?)
•  CMS Official Answer:
–  The physician absolutely should receive credit if he documents this.
what Jim just provided is valuable information and should be documented.
–  It is not "negative". It is a fact that there are no modifying factors that
influence the SOB and there are no other accompanying symptoms.
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History of Present Illness
location: the area of the patient’s body affected
Atrial Fibrillation
quality: distinctive characteristics of the problem
Sharp chest pain
severity: intensity of the symptoms or problem
Pain is a 7 on a 1 to 10 scale
duration: how long the problem has been present
Diagnosed with diabetes 2 years ago
timing: a description of when the symptoms exist
Symptoms are worse in the evening
context: Wild Card
modifying factors: anything that modifies the condition
Symptoms are aggravated with exertion and reviewing E&M rules
associated signs and symptoms: conditions related to the problem
Patient also has shortness of breath
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Context
•  NHIC: Context is the situation
associated with the pain/symptom
(dairy products, big meals, stair
climbing, and injured ankle playing
basketball).
•  Palmetto GBA Context –
circumstances, cause, factors
surrounding the complaint. What was
the patient doing when the signs/
symptoms occurred — Pulling weeds
— Jogging- While standing
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History
1
2
3
4
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“NonContributory”
Noridian:
Ques=on:Iffamilyhistoryis
noncontributorytotheacute
problemandisnotaskedbythe
physician,maywecount"familyhx
=noncontributory"asfamilyhx
towardsROS?
Answer:No,ifnotinquiredabout
andifithasnothingtodowiththe
chiefcomplaint,familyhistory
wouldnotbecounted.
Na*onalGovernmentServices
•  Palmetto GBA:
–  Question: Is it acceptable to use 'noncontributory, unremarkable or negative'
when reporting past, family or social history?
–  Answer: No, because the statement 'noncontributory, unremarkable or
negative' does not indicate what was addressed.
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Sloppy & Paste History Elements
•  “A ROS and/or a PFSH obtained during an earlier
encounter does not need to be re-recorded if there is
evidence that the physician reviewed and updated the
previous information. …. The review and update may be
documented by:
–  describing any new ROS and/or PFSH information or noting
there has been no change in the information; and
–  noting the date and location of the earlier ROS and/or
PFSH.
•  The ROS and/or PFSH may be recorded by ancillary
staff or on a form completed by the patient. To
document that the physician reviewed the information,
there must be a notation supplementing or confirming
the information recorded by others.”
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Contradictions Are Common
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Unable to Obtain History
•  “If the physician is unable to obtain a history from
the patient or other source, the record should
describe the patient's condition or other
circumstance which precludes obtaining a history.”
–  Intubated
–  Sedated
–  Unconscious
•  The guidelines stop short of awarding credit for the
unobtainable history elements.
•  It’s safest to rely on exam and complexity
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History & Exam:
1
2
3
4
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National Govt. Services: EPF vs. D
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Hidden Organ Systems
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Overview of Complexity
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#1
Complexity Variable # 1 of 3: Type of Problem(s)
Points
For Each
1
Established problem(to examiner); stable
Established problem(to examiner) worsening
2
New problem(to examiner);no additional work-up
3
2 supports:
99203 visit
(new),or99213
(admit), 99231 (subs.4hosp)
New prob.(to examiner); addtl. work-up planned
(same
next(est),
per99221
NGS)
3 supports: 99204 (new), 99214 (est), 99222 (admit), 99232 (subs. hosp)
4 supports: 99205 (new), 99215 (est), 99223 (admit), 99233 (subs. hosp)
Total Points:
#2 Complexity Variable # 2 of 3: Variety of Data
Points
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology sections of CPT
Review and/or order of tests in the medicine sections of CPT
Discussion of test results with performing physician
Review and summarization of old records and/or obtaining history from someone other
than patient and/or discussion of case with another health care provider
Independent visualization of image, tracing or specimen
1
1
1
1
2
2
Total Points:
1 supports: 99202 (new), 99212 (est)
99231 (subs. hosp)
2 supports: 99203 (new), 99213 (est), 99221 (admit)
3 supports: 99204 (new), 99214 (est), 99222 (admit), 99232 (subs. hosp)
4 supports: 99205 (new), 99215 (est), 99223 (admit), 99233 (subs. hosp)
Source: Marshfield Clinic Audit Tool distributed by CMS
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Independent Visualization
•  “QUESTION: The audit tool referenced above awards two
credits for independent visualization of an image, tracing or
specimen itself (not simply review of a report.) The tool also
awards one credit for ordering a diagnostic test. If the
physician ordered a test (such as an EKG) and he/she
personally reviewed the tracing on the same day would he/she
be awarded credit for both the order (1 credit) and the
personal review (2 credits?)
•  RESPONSE-----Yes. They are two separate activities. If you
order it you might not get to review it. If you do review it/
look at it in a scope etc and make make judgments then
documenting this activity should allow you to have credit for
both ordering and reviewing it (not just reading a report).”
•  CMS Director of External Affairs
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Independent Visualization
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Minimal supports:
Low supports:
Moderate supports:
High supports:
99202 (new), 99212 (est)
99231 (subs. hosp)
99203 (new), 99213 (est), 99221 (admit)
99204 (new), 99214 (est), 99222 (admit), 99232 (subs. hosp)
99205 (new), 99215 (est), 99223 (admit), 99233 (subs. hosp)
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Prescription Drug Management
•  “A new prescription is not required for this level.
The medical record documentation must show you
are either writing a new prescription for the patient
or evaluating any current prescriptions, including
determining whether the drug, dosage, and
frequency are still appropriate for the patient's
condition.”
•  Intensive monitoring for toxicity - Cardiac
Examples: Digoxin, digitoxin, quinidine,
procainamide, & amiodarone.
CMS Director of External Affairs
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The Time Alternative
•  “the specific times expressed in the visit code descriptors are averages, and
therefore represent a range of times which may be higher or lower depending
on actual clinical circumstances. The content of the service is used to select
the appropriate level of E/M service. In the case where counseling and/or
coordination of care dominates (more than 50%) the face-to-face physician/
patient encounter, then time is considered the key or controlling factor. The
extent of counseling and/or coordination of care must be documented in the
medical record.” CPT Assistant Winter, 1999
•  “When codes are ranked in sequential typical times and the actual time is
between two typical times, the code with the typical time closest to the actual
time is used” CPT Assistant October, 2011
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Time Based Billing: An alternative to History, Exam, & Complexity
To bill based on time, your note must establish two things:
1)  Face-to-Face time (office) or Unit/Floor time (hospital)
2)  Majority of time was in Counseling or Coordination of Care
• 
• 
• 
New Pt. Office Visit
–  99201 – 10 min.
–  99202 – 20 min.
–  99203 – 30 min.
–  99204 – 45 min.
–  99205 – 60 min.
Established Pt. Office Visit
–  99211 – 5 min.
–  99212 – 10 min.
–  99213 – 15 min.
–  99214 – 25 min.
–  99215 – 40 min.
Outpatient Consultation
–  99241 – 15 min.
–  99242 – 30 min.
–  99243 – 40 min.
–  99244 – 60 min.
–  99245 – 80 min.
Sample 99215:
“I spent 40 minutes
with the patient;
the majority of this time was
spent discussing heart failure
treatment options.”
Observation Admission
99218 – 30 min.
99219 – 50 min.
99220 – 70 min.
Subsequent Observation Care
99224 – 15 min.
99225 – 25 min.
99226 – 35 min.
Initial Inpatient Care
99221 – 30 min.
99222 – 50 min.
99223 – 70 min.
Subsequent Inpatient Care
99231 – 15 min.
99232 – 25 min.
99233 – 35 min.
Inpatient Consultation
99251 – 20 min.
99252 – 40 min.
99253 – 55 min.
99254 – 80 min.
99255 – 110 min.
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0%
1
0
Propaganda Graphs
Established Patient OV
60%
5
50%
4
40%
30%
3
20%
10%
2
0%
1
0
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Initial Hospital Care
Handwritten Signature
•  "I, the author, am responsible
for the accuracy of all the
information contained in this
note.”
Mouse Click
•  "My electronic signature
affirms that the copy-andpasted portions in this note
have been accurately copyand-pasted from earlier notes.
The responsibility for the
accuracy of copy-and-pasted
text does not reside with the
current author, but instead,
with unnamed previous
authors.”
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HHS & DOJ Joint Initiative
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Scribing: CMS Guidance
•  “the scribe should be merely that, a person who writes
what the physician dictates and does. This individual
should not act independently.”
•  In order for scribes to make entries in the medical
record:
–  They must document exactly what the physician tells them,
–  They must refrain from documenting any personal observations, and
–  They must not see the patient in a clinical capacity.
TheMedicareCondi=onsofPar=cipa=on,Sec=on482.24,c,1,requirethat
“Allentriesmustbelegibleandcomplete,andmustbeauthen=catedand
datedpromptlybytheperson(iden=fiedbynameanddiscipline)whois
responsibleforordering,providing,orevalua=ngtheserviceprovided.The
authorofeachentrymustbeiden=fiedandmustauthen=catehisorher
entry.Authen=ca=onmayincludesignatures,wri@enini=alsorcomputer
signatures.”
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AHIMA insight
•  American Health Information Management Association, “Legal
Documentation Standards” This reference (available online at:
http://www.ahima.org/infocenter/guidelines/ltcs/5.1.asp)
•  “Every entry in the medical record must be authenticated by the
author – an entry should not be made or signed by someone
other than the author. This includes all types of entries such as
narrative/progress notes, assessments, flowsheets, orders, etc.
whether in paper or electronic format.”
•  “Authors must always make and sign their own entries (both
manual and computerized records). An author should never
make an entry or sign an entry for someone else or have
someone else make or sign an entry for them.”
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False Statements Relating to Health Care
Matters (18 U.S.C. 1035)
“Description of Unlawful Conduct
It is a crime to knowingly and willfully falsify or conceal a
material fact, or make any materially false statement or use
any materially false writing or document in connection with
the delivery of or payment for health care benefits, items or
services. Note that this law applies not only to Federal
health care programs, but to most other types of health
care benefit programs as well.
Penalty for Unlawful Conduct
The penalty may include the imposition of a fine,
imprisonment of up to 5 years, or both.”
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Contact Info
•  Jim Collins, CPC, CCC
•  [email protected]
•  518.320.4376
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IMPORTANT NOTE:
Health economic and reimbursement information provided by OptimalDocumentation.Com and
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a result of complex and frequently changing laws, regulations, rules and policies. This information is
presented for illustrative purposes only and does not constitute reimbursement or legal advice. We
encourage providers to submit accurate and appropriate claims for services. It is always the provider’s
responsibility to determine medical necessity, the proper site for delivery of any services and to submit
appropriate codes, charges, and modifiers for services that are rendered.
CPT Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of
the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the AMA,
are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly
practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein. All other material is Copyright 2016, CardiologyCoder.Com, Inc.
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