Optimize your documentation to improve Medicare reimbursement

OVERVIEW OF GENERAL MEDICAL BILLING IN OUTPATIENTS

The Current Procedural Terminology (CPT) codes used in outpatient billing for evaluation and management are typically divided into 5 levels for new patients (99201–99205) and established patients (99211–99215), determined by the number of topics documented in the history, physical examination, and medical decision-making.

For a new patient, all 3 sections must meet the criteria for the level in order to bill for the corresponding level (Table 1).^1,2 For instance, if the history and the physical examination are documented to a level 3 standard, and the medical decision-making is documented to a level 4 standard, then the overall visit will count as a level 3, despite the medical decision-making, because the history and physical were not documented at the level 4 standard.¹ (A new patient is defined as one who has nev er been seen by a physician in your group, or as a patient who has not been seen in 3 years.)

In an already-established patient, only 2 of the 3 areas need to meet the documentation criteria in order to bill at a specific level (Table 2). For example, if the history and examination meet the criteria for level 4, and the medical decision-making meets the criteria for level 3, the note can still be billed as a level 4.

As a side note, billing based on time is an acceptable alternative. However, significantly more time (30 minutes) is required to bill at a level 3, which is typically completed in the 15-minute patient time slot allotted in most clinics. When billing based on time, the history, examination, and medical decision-making do not need to hit the required level of documentation.^1,2

GERIATRIC BILLING: DETERMINING THE VISIT TYPE

It is important to classify geriatric visits into 2 separate categories: the new wellness visit and the standard office visit. This is essential because while a large portion of preventive services (depression screening, advance care planning, smoking cessation, sexually transmitted diseases screening, alcohol counseling, weight counseling, and heart disease counseling) can be administered at either category of visit, a cognitive assessment is only billable during a wellness visit or a specific visit for cognitive assessment.² See Table 3 for the complete inclusion criteria.

However, if the patient presents for a wellness visit with a separate chief complaint, it is also allowable to “split-bill” the visit as both a wellness and standard visit as long as 2 separate notes exist for the encounter. The caveat is that a patient can only be billed for a wellness preventive visit once per year, but split billing can often dramatically increase the Relative Value Units (RVUs) generated by a single wellness visit.

THE ANNUAL WELLNESS VISIT

The annual wellness visit (AWV) is an incentive visit provided by Medicare. Many people refer to the AWV as “the yearly physical,” which is a misconception. The AWV is simple, and its main focus is to perform a health risk assessment and create a personalized prevention plan.

There are 2 billable codes for an AWV: G0438—initial annual wellness visit, which can only be assigned once in a patient’s life, and G0439—subsequent annual wellness visit.³ Of importance, certain documentation is required to bill for these codes (Table 4).

As a side note there is a “Welcome to Medicare” visit code (G0402) that is considered an Initial Preventive Physical Examination (IPPE) and not a billable code for AWV. The IPPE is covered only once within the first 12 months of Medicare Part B enrollment. The goal of the IPPE is essentially to review medical and social history along with health promotion, education, disease prevention, and detection. The initial AWV (G0438) can be offered 12 months after the patient received the IPPE or 12 months after the patient was enrolled under Medicare Part B. A subsequent wellness visit (G0439) can be offered annually.^2,4

For more detailed information see: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf.

This may seem like a lot of documentation, but with appropriate staff coordination, previsit data collection, and appropriate templates it will not take more than 20 minutes with documentation included.^3,4 Table 5 is a sample note with the required documentation to bill for an annual wellness visit.

COGNITIVE ASSESSMENT

Cognitive assessment is an examination to evaluate a person’s cognitive level, remaining abilities, and capacity to function. It can be provided to any patient who exhibits any signs or symptoms of cognitive impairment,³ in either a wellness visit or a specific cognitive assessment visit (see below).

Several standardized tests are available to be used by any eligible medical provider (physicians, nurse practitioners, clinical nurse specialists, and physician assistants). Some acceptable tools to assess cognition are the Mini-Cog, Montreal Cognitive Assessment, Mini-Mental State Examination, Saint Louis University Mental Status Examination, Memory Impairment Screen, and AD8 Dementia Screening Interview.^5,6

MAXIMIZING PREVENTIVE SERVICES

Regardless of the chief complaints, many clinics have adopted automatic screening questions or quality metrics to assess patients’ overall health, such as body mass index monitoring, screening for smoking and alcohol use, or even “health vital signs” such as asking patients to estimate how much exercise they perform in a week. Often, these screening questions are given to the patient on a paper form to fill out while waiting for the doctor’s visit.^6,7 The reason these monitoring metrics are included is to maximize the billing for any particular encounter.

To optimize potential for billable preventive services, annual wellness screening paperwork should include questions regarding depression, alcohol use, tobacco use, sexually transmitted disease risk factors, and cardiovascular risk factors. A positive answer on any of these screens should prompt a brief discussion during the encounter with the appropriate billing code and time documented. The reason for including these questions on the AWV is that many counseling services can only be billed for once a year.^7,8

To maximize preventive services, wellness visits should be set for at least a 30-minute time slot, not only to manage whatever chief concern the patient brings, but also to address as many positive screening questions as possible. Furthermore, having more time in the wellness visit allows for overlapping counseling such as smoking cessation, cardiac risk factor counseling, and alcohol cessation to ensure the time criterion is met for each topic. See Table 7 for the requirement time for each billable code, RVU value, and the required interval of time before each service can be billed for again.

DOCUMENTING FOR PREVENTIVE VISITS

To receive compensation from Medicare for a preventive service, 3 components must be documented,⁸ ie, the amount of time spent counseling, the CPT code, and the linked diagnosis. This will improve Medicare reimbursement for the preventive services that a primary care physician regularly provides. However, these services are not exclusive to primary care physicians: they can be billed for by any medical specialist as long as they are properly documented and not billed by another physician (usually the primary care physician) in the specific required interval for that service. For example, if a primary care physician documents and bills for a particular service after a subspecialist does, the primary care physician won’t get reimbursed.

For more detailed information see: https://www.cms.gov/Medicare/Coding/MedHCPC-SGenInfo/index.

The time documented in the services requiring time attestation cannot overlap be tween the time for the standard office visit and the time for other preventive services. See Table 8 for examples of time attestation.

REIMBURSEMENT FOR CARE PROVIDED

The role of the primary physician is to provide comprehensive care to the individual. But often, the care provided is not reflected in the Medicare reimbursement as a result of incomplete or inadequate documentation. While initially daunting, proper optimization of the clinic visits to include previsit screening questions, increased time slots for wellness visits, and note templates with prebuilt preventive coding can dramatically increase the RVUs generated for services that most physicians already provide.