Question

An employee of a physician practice, who is not authorized to release a patient’s billing information (i.e. transcriptionist) shares a patient’s outstanding balance and other billing information with another individual. Has the employee inappropriately disclosed the patient’s PHI?

Answer

Yes. The employee’s actions constitute a breach if the employee released the patient’s financial information without the patient’s authorization and for purposes other than payment or healthcare operations. The privacy rule specifically addresses billing information.

Any information pertaining to a patient (demos) is considered PHI and thereby has the protection of the privacy rule.

Employees responsible for a breach of PHI – a federal crime since February 17, 2009 under the HITECH Act – should (may) be subject to sanctions.

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Ultimately, the focus is turning to clinical quality measure data collection which will shift payment methodology to performance improvement. Clearly, the slow migration has begun to establish a pay-for-performance reimbursement system where clinical data will help drive quality improvement in health care. CMS is required to develop a plan by 2010 outlining how to integrate the PQRS measures with the EHR meaningful use incentive program. The 2011 proposed rule specifically sought comments on how best to align the two incentive programs and stated:

“In an effort to align PQRI with the EHR incentive program, we propose to include many American Recover and Reinvestment Act (ARRA) core clinical quality measures in the PQRI program to demonstrate meaningful use of EHR and quality of care furnished to individuals. We propose the selection of those measures to meet the requirements of planning the integration of PQRI and EHR reporting.”

Although claim based reporting is still allowed, CMS has reported there is only a 50% success rate (in 2009), while using a registry the success rate jumped to 90%. What’s the better option of the two? Both have negatives and positives. See the chart (as printed in AAPC) below. Decide which will work best for your practice.

To learn more about PQRS codes, go to: www.cms.ggov/PQRI/15_MeasuresCodes.asp#
Go to the link labeled “Additional 2011 Physician Quality Reporting System Measure Documents” – open 2011 PQRS measures groups specifications manual.

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More About Medical Billing Finances

On March 8th, 2011, posted in: Tips by

You aren’t imaging things. Yearly deductible amounts have increased, so have co-pays. Remember, it is the patient’s contract with the insurance carrier that mandates their compliance with the plan and their responsibility for payment. It is your responsibility to collect (or try to the best of your (our) ability) these fees.

I am making a generalized statement here – most if not all carriers state the patient must pay the co-pay at the time of service. Remind the front desk to ask for the new card, it will (should) indicate if the co-pay amount has changed since the last visit.

Prior to elective surgical procedures, your precertification department can also check benefits. While it won’t be totally accurate, if will give you an idea of what the patient still owes toward their annual deductible. Collect a portion of that prior to surgery. I would rather have you writing a refund, if necessary, than the patient claiming they don’t have the money to pay you after the fact.

Change your practice culture. You may consider:

  • Retrain your staff and their attitude about money. Teach them how to speak to patients about it.
  • Determine how much the patient owes you. Use the on-line tool we provide – always phone if you have questions
  • Get the patient’s coverage information at the time of scheduling the appointment
  • At the time of scheduling, tell the patient they are responsible for co-pay payment prior to seeing the physician. Ask them to come prepared to pay it.
  • If surgery is being scheduled, the surgical scheduler can address the potential need for some payment prior to surgery. Tell the patient to be prepared with a credit card when your employee phones them with details of the upcoming surgery
  • Provide a payment option – split the outstanding balance over a few (not a year) months time frame
  • If the patient does not have a credit/debit card with them, remind them they can ‘pay on line’ at: www.pmabillpay.com. Tell them what their balance is and ask them to pay it when they return home. The site will prompt them for your name, their name, payment information, etc. We download these payments each morning, communicate the payment information to you to enter into your credit card machine, you tell us it was approved; we post the payment to the account. This option always appears on the patient’s monthly statement.
  • Once again consider CareCredit. The application is done in your office, you get paid and the patient deals directly with CareCredit regarding their ‘medical credit card’ payment.

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Global Period – Compliance Question

On March 8th, 2011, posted in: Tips by

Some physicians in our practice like to extend the global period for surgical procedures in order to provide continued free care to patients because they believe the patient has some financial hardship. Can we do this?

NO. You cannot arbitrarily extend the global period of a surgical procedure to save the patient money. If you do not charge for those visits beyond the global period to help a patient out financially, you run the risk of noncompliance with a variety of statutes and regulations, including federal false claims and Stark anti-kickback laws, CMS coding guidelines and commercial carrier contracts.

If the patient needs financial assistance, you must dig out the practice financial policy and have the patient provide all necessary documentation to prove he cannot afford your charge, partially or in full. Keep the documentation in your chart and remember this ‘courtesy’ applies to the visit in question only. It should not be considered as a ‘forever’ forgiving policy. If the patient can only pay a portion of the bill, get it in writing and settle on a monthly payment that takes no more than 3 or 4 months to settle the balance.

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When you, the nurse or medical assistant spend time helping a patient with an inhaler demo or evaluation, keep in mind these things:

  • What type of device you are using
  • Documentation
  • Qualifying modifiers

If you are providing separate education after the patient has received an inhalation treatment on the same day, you will be able to report 94664 twice, the second code appended with a ‘59’ modifier to indicate that the procedure was for teaching purposes.

The bottom line, documentation and medical necessity for the services performed. You are entitled to payment (about $16.00) for this service each time it is provided. The approved diagnosis would always be a respiratory code. As example: 493.01 Extrinsic asthma, with status asthmaticus or 493.22, chronic obstructive asthma.

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Pain providers may see more denials this year. SI injections (27096), epidurals (62310-62319) paravertebral facet injections (64490-64495) and greater occipital nerve blocks (64405) are now designated as “Anesthesia Care Not typically required” in the American Society of Anesthesiologist (ASA) 2011 Crosswalk.

Many insurance carriers use the ASA crosswalk as their guide for linking procedures together. When the carrier sees the new designation for the anesthesia services, they may issue a denial. To achieve payment, you will need to prove services were medically necessary due to an underlying condition requiring the patient to be monitored throughout the service or a condition that prevented the patient from holding still or lying prone for the duration of the procedure.

Pain and anesthesia practices should look at local medical policies to determine if carriers deem the use of a second physician necessary to provide anesthesia during interventional pain management procedures. Just because you may not find a LCD (local carrier determination), doesn’t mean medical necessity isn’t an issue. LCD’s are often updated long after the fact and medical necessity is always the underlying issue for any patient, anytime and for every procedure.

One Medicare carrier (Care First) has issued this policy for monitored anesthesia care codes (01991-01992) during interventional pain management services.

“The patient’s medical condition or nature of the procedure requires the presence of a second physician represented by an anesthesiologist or qualified anesthesia provider to administer the sedation if utilized to manage the airway & vital signs, and to continually assess the patient for clinical problems and treat appropriately to ensure patient safety and comfort.”

“The presence of an underlying condition alone or a stable treatable condition is not sufficient evidence that monitored anesthesia care is medically reasonable and necessary.”

According to First Coast, some conditions that demonstrate medical necessity:

  • Co-morbidities such as pulmonary disease, cardiac disease, morbid obesity, severe sleep apnea
  • Inability to follow simple commands caused by developmental delay or dementia
  • Spasticity disorders that would make it difficult for the patient to lie still
  • Severe anxiety immediately prior to the procedure which may affect patient safety and comfort
  • The patient is a Medicare –eligible pediatric patient

A diagnosis alone will not prove medical necessity. The patient’s condition must be significant enough to impact the need to provide MAC (such as the patient being on medication or symptomatic, etc.). The presence of a stable, treated condition is not generally sufficient medical justification for MAC, First Coast writes. They go on to give an example:

“An otherwise healthy patient who suffers from senile dementia with delusional features (290.20) is scheduled for a single-level lumbar paravertebral face injection (64493). However, the patient is able to understand and follow instructions, holds still for the duration of the procedure and shows no signs or symptoms of unusual anxiety before the procedure. The carrier would issue a medical necessity denial for anesthesiologist’s services.

When you are scheduling the case, indicate the medical necessity to your scheduler. It may assist in the precertification process and potentially help with appealing the denial, if necessary.

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Guidelines for EXTREMITY Ultrasounds

On March 8th, 2011, posted in: Tips by

CMS is taking a hard look at the significant increase use of code 76881 and 76882. They have also issued specific guidelines for the correct use of each of these codes. Let’s take a look.


Complete:
The guidelines instruct that complete code 76881 includes real time ultrasound scans of a joint. To be complete, the documentation should reference related “muscles, tendons, joint, and other soft tissue structures, and any identifiable abnormality.”

Example: CPT Changes 2011: An Insider’s View offers the example of a complete exam of the ankle, including the following:

  • Lateral structures (for example, peroneus tendons; fibular ligaments)
  • Medical structures (….posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons; deltoid ligament; neurovascular bundle)
  • Anterior structures(….tibialis anterior tendon; ankle joint)
  • Posterior structures (….Achilles tendon; retrocalcaneal and retroachilles bursa)

Limited:
In contrast, limited study code 76882 applies to the examination of specific anatomic structure, including muscle, tendon, joint or other soft tissue.
Guidelines for 76882 also explain that the code is appropriate for evaluation of a soft-tissue mass if the physician needs to learn its cystic or solid characteristics.

Example: CPT Changes 2011: An Insider’s View offers the example of the Achilles tendon for an injured patient. This limit exam would code as 76882.
Example: A diabetic patient presents with pain and swelling of the left leg. The physician performs an ultrasound to determine the presence of an abscess. In this case, it is still a limited exam and you would report 76882.

NOTE: This article did not address the use of either code for PRP injection or ultrasound guided injections. At this time each carrier has their own coverage criteria which aren’t necessarily in writing. Most have been allowing reimbursement for guidance, and some others are stating that the procedure is “out of your scope of practice”, if you are not a radiologist.


HOWEVER, the current CCI edits state you should not report 77002 (fluoroscopic guidance for needle placement, e.g. biopsy, aspiration, injection, localization) when you administer trigger point injections (20552-20553) or administers tendon sheath injections (20550-20551). The code does have a ‘1’; which means if you can justify the use of guidance, you can override the bundling with a modifier. Yes I know this is talking about fluoro, and the rest of this article is about ultrasound. With the increase use of ultrasound, it may be just a matter of time until they bundle that into these codes as well.

Remember statements cannot be made about carriers specifically as many coverage guidelines are patient plan specific. Bottom line, I’m not sure I would scan every patient that walks through your door. Use common sense and medical necessity.

Also as a reminder Medicare will not pay for ultrasound guidance of a knee joint unless specific criteria are met; bakers cyst, failed previous injection, and obesity morbid enough that it is impossible to inject the joint space without guidance. If any of this is the case, document, document, document.

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Physical Therapy – Attaining New Patients

On March 8th, 2011, posted in: Tips by

In a recent publication of Specialty Alerts, there was a “Therapy Trigger Tool” which was created by TMF Quality Institute. In the article it was stated that this tool was a simple check list that is to be distributed to physicians and other providers in your area to assist them in determining when a patient needs therapy.

For your review, I am attaching this form. The article also suggested you customize the form to fit your therapy practice and to remember to include you contact information, name, address, phone, email, web site, etc. The purpose? The article suggested this would be a way for other providers to easy spot and assess a patient in need of therapy.

Give it a look. It just may be the simplest thing you have done to bring new patients to the practice.

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Incident To Documentation Reminder

On March 8th, 2011, posted in: Tips by

CMS is looking for evidence that services were performed under physician supervision. Why? Instead of billing under the PA/NP’s individual NPI and receiving 85% of the allowed amount, more practices are going back to incident-to billing in order to receive 100% of the allowed fee schedule.

What to you need to do? It is as simple as adding the following statement to your documentation:

“Services performed under the supervision of Dr. ___________.”

Co-signatures are not required for billing purposes.

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Of late, some carriers are pending payment of CTS injections and requesting documentation to see if other treatments have failed.
Although, you the orthopedist have more than likely tried treatments such as splints, medication or OT/PT prior to injecting, the patient in some cases, may present to you as a new patient and request the injection at this first visit. Whatever the scenario, your documentation should include the previous therapies tried and failed either prescribed by you or the patient’s PCP.

Remember to indicate that the patients symptoms are worsening and also document a positive Tinel’s sign and/or a positive Phalen’s maneuver.

Examples of what to include in the documentation may look something like this:

  • Nighttime wrist splint therapy began_________
  • Weekly PT sessions, strength and stretching regime began__________
  • Steroidal therapy began _______________
  • Patients states____________did not help and symptoms began to become worse____________

Your diagnosis, ICD-9 – 354.0 – will become G56.00 with ICD-10.

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