April 17, 2019

Evaluation and Management Documentation Changes in 2019

The Patients Over Paperwork initiative was designed to “cut the red tape” and streamline administrative tasks placed on physicians so they can focus on patient care. In the 2019 Final Rule, CMS has agreed to:
·         Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to redocument information;
·         Clarify that for both new and established E/M office visits, a chief complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered;
·         Eliminate the requirement for documenting the medical necessity of furnishing visits in the patient’s home versus in an office; and
·         Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.
In practical terms, this means physicians no longer have to redocument information already entered by patients, ancillary staff, or residents, and information already documented at a previous visit. It is important to recognize, however, that all information used to calculate the level of Evaluation and Management (E/M) service must be clearly referenced, reviewed and verified. When information is already documented for History and Exam components, for example, the billing clinician can review the information with the patient, update or supplement as necessary, and document in the medical record that he or she has done so. The exam still needs to be completed, it just doesn’t have to be redocumented if, for instance, most of the elements are normal.
For example,
“I have reviewed and agree with the information documented above.” Exam is consistent with my previous assessment on 12/30/2018, except for lungs, which are clear on auscultation today.”
Any payor requests for medical records will need to include all referenced documentation, so staff will need to carefully review the documentation before sending medical records for review.
All of the other proposed changes to E/M services are postponed for two years. In 2021, physicians will have these options to code for office and outpatient services:

·         Continue using 1995 and/or 1997 guidelines;
·         Base the level of services solely on medical decision making (MDM);
·         Choose the level based on total time of the visit, not only when 50% is spent in counseling and coordination of care;
·         Two new bundled codes for Medicare that will combine levels 2 – 4, but only require the documentation of a level 2 new or established patient visit.
Deciding which method to use will be a challenge at first, but it will be important to use the method that results in the highest reimbursement for the provider. If you need assistance conducting an analysis on the impact to your revenue, please contact the Integrity Health Strategies for assistance.

March 26, 2019

2019 CPT and HCPCS Changes

New CPT® codes and telehealth HCPCS codes from CMS were effective 1/1/2019 and could be significant for you depending on your specialty. Here is a brief summary of just a few of the key changes you should be aware of as they may affect your practice. This is not an all-inclusive list, so please refer to the 2019 CPT®, HCPCS, and ICD-10 codebooks for a full description of the codes to ensure appropriate coding and reimbursement in 2019.

TWO NEW E/M TELEHEALTH CODES (99451 and 99452) are now available for written interpersonal telehealth communication between consulting and treating/requesting providers. Three codes (99453, 99454, 99457) were added for remote physiologic monitoring services.
Two HCPCS add-on codes are for Prolonged preventive service(s) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (G0513) and each additional 30 minutes (G0514).These codes are billable with appropriate telehealth preventive services (available on the CMS website). 
Medicare also added code G2012 for a “virtual check” – 5 to 10 minutes of medical discussion with the billing provider when an office visit is not deemed necessary. Code G0212 requires documentation of the patient’s verbal consent as well as the total time spent discussing the patient’s condition.
MODIFIER G0 was added for telehealth services furnished for diagnosis, evaluation, or treatment of symptoms of acute stroke.
Codes 10022, 11100 and 11101 were deleted for fine needle aspiration (FNA) and skin biopsies. Code 10021 was revised to include “without imaging guidance”, while several new codes represent FNA biopsies with imaging. 
The other sections of CPT® had various changes as new and advanced procedures made their way into CPT®. There are many new and revised codes in the Medicine section and Category III codes, including one new flu vaccine code, electroretinography services, developmental, psychological and neuropsychological testing just to name a few. Please refer to 2019 CPT® for a full description of all changes. If you have any questions about the new codes or need education for your practice on the changes, please contact Carol Hoppe at
REFERENCESCPT© 2018 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.New Modifier for Expanding the Use of Telehealth for Individuals with Stroke MLN Matters Number: MM10883 Related CR Release Date: September 28, 2018 Related CR Transmittal Number: R2142OTN Related Change Request (CR) Number: 10883 Effective Date: January 1, 2019 Implementation Date: January 7, 2019

Carol Hoppe, CPC, CCA-P, CPC-I
p: 317.819.7709

January 10, 2019

Are You Ready For 2019?
byCarol Hoppe

It's hard to believe it's already January 2019. As we look at the year ahead, there are so many uncertainties in healthcare. It seems like changes are occurring faster than we can keep up with. Do you have a game plan for 2019?
  • Are your providers ready for the changes in E/M documentation requirements being implemented by CMS?  
  • How will you address these changes with commercial payers? 
  • Are you performing and capturing all that can and should be billed for including Annual Wellness Visits, Transitional Care Management, and Chronic Care Management services, which are covered by Medicare and most commercial payers?
  • Are you ready for the new CMS Targeted Probe and Educate (TPE) medical reviews focused on commonly found documentation and coding errors? 
  • Are you working with your providers on value-based reimbursement methodologies and the importance of accurate HCC-based diagnosis coding?
We are here to help with many of the billing, coding, training and practice management needs you may have, such as:
  • E/M Coding Education
  • E/M and Surgical Chart Reviews
  • Physician Shadowing and Side by Side Training
  • HCC Coding Education
  • ICD-10 Training
  • Payer Fee Schedule Analysis
  • A/R Analysis
  • Denial Management Solutions
  • Payer Audits and Appeals
  • Revenue Cycle and Efficiency Assessments
  • Interim Onsite Project, Planning and Consulting Services
Please let me know if you have plans for E/M or specialty specific coding education and/or chart reviews in 2019, so we can plan accordingly and get you on our schedule. 

Carol Hoppe, CPC, CCA-P, CPC-I
p: 317.819.7709