Appropriate documentation of prescription drug management continues to be an opportunity for many physicians. Doctors need to know that simply adding the current medication list to the progress note is not adequate to include in the level of risk of a moderate visit.
Prescription drug management is based on documented evidence that the physician has evaluated medications as part of a service that is provided. Physicians should make a direct connection between the medication that is prescribed to the patient and the work that was performed on the day of the clinic visit, such as Stable hypertension; continuing Valsartan 10 milligrams, will refill for 4 months until next follow-up visit. Simply stating that the medication list was “reviewed” will not meet the definition of prescription management.
It would have been helpful if 2021 or the updated 2023 Documentation Guidelines, had been defined within the guidelines of Rx management to finally put to rest much of the ambiguity within the auditing world, but unfortunately, AMA did not. Many MACs have published guidance on this topic, and Noridian is pretty clear. Their guidance states: Prescription drug management is the initiation, continuation, discontinuation, or modification of any prescription medication. This does NOT include medications that are OTC and prescriptions that are ONLY prescribed for insurance benefits.
Keep in mind that patient convenience and reimbursement rules NEVER make such determinations. A keyword in the description that causes confusion is “management”. Oftentimes, coders/auditors hear the word management and infer that this would mean a longtime use of a prescription drug; but look up the word.
Management in healthcare is defined as the coordination and administration of tasks to achieve a goal.
How to determine Rx Management:
Again, simply stating in the medical record that the physician renewed a prescription “for a patient” or “continue meds” without further management discussion, does not meet the risk criteria in the Medical Decision-Making table, nor does it warrant an E/M service on its own.
Please remember that prescription drug management is based on the documented evidence in the record showing the provider has evaluated medications during E/M service as it relates to the patient. Simply listing medications that the patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place regarding those medications.
This information has been added to the Medical Decision-Making section of NGS Medicare, and many other MAC websites, have similar language on their Evaluation and Management Frequently Asked Questions web page.
In this climate of texting and wanting quick results for everything from ordering your lunch, to ordering medical tests, to attending a meeting with a speaker who uses a lot of acronyms that you are expected to know, let’s save some time and offer you a reference tool so you aren’t going to “Dr. Google” when trying to be present in your education as a medical professional.
Make sure you have this handy when you are needing to reference a particular regulatory guidance, speak to a physician, or listen in to an educational webinar. This will assist so you are not in the dark.
When you need answers to coding, billing, and reimbursement questions, who do you turn to? I am sure it isn’t Ghostbusters!. If you are a Coding Corner member or Executive member, you can get unlimited coding and billing questions responded to for a yearly fee. (See our Coding Corner Webpage for pricing.)
Here are a few Q&As over the last few weeks that have caught my attention and I believe could assist many in their workflows and coding processes. Enjoy!
Answer: “For RPM or any device monitoring, it is Best Practice to report the service when it is completed, as you might have to produce a report if asked. So the date that the patient returns the device or the date that the physician documents the final read is the best date of service to use for billing. You may find another payer that will allow billing on the date of hook up, but that would be rare.”
Answer: 45385 and 45381-51 same polyp or lesion and not bundled as long as it is to help lift the lesion for removal and not to mark the space for a planned future procedure.
Answer: Look at 19300 for mastectomy for breast tissue removed for breast-sized reduction for gynecomastia, but if the breast tissue was removed for a reduction only, and there is no gynecomastia diagnosis, then use code 19318
Answer: For bilateral lower extremity stenting, the CPT® 2022 Professional Edition gives us modifier direction of this scenario at 37221, and 37221.59. It seems like a -50 modifier would be more appropriate since this is a bilateral procedure, but CPT® overrules this coding application in the section for LE interventions.
Answer: 37236 and add-on code +37237 – there is no side-to-side or unilateral or ipsilateral offering. Only initial artery and additional artery.
Answer: If the physician reports a level 5, 99205, or 99215 for a Medicare patient and meets the “maximum” required time allowed for either code and then adds 15 minutes of clinical time, the provider can add the modifier G2212, which is a crosswalk to the add on code for prolonged services +99417. If the patient is a non-Medicare patient, CPT® allows for the minimum time of a level 5 to be met, and the additional 15 minutes, but we submit that Best Practices would be to follow CMS rules on this, as it makes more sense.
Answer: I would recommend using CPT code 37236 for the placement of a stent (or stentgraft) when the device is placed to treat a bleeding vessel. Had this hemorrhaging vessel been somehow treated with coils, it would be coded as an embolization with CPT code 37244. If both coils and a stent were used to treat the same pathology, we would only code for the embolization. Code 37226 is for the placement of a stent in the femoral/popliteal region for the treatment of occlusive disease, while code 37236 is used when a stent or stentgraft is placed for the treatment of non-occlusive disease (bleeding, AVM, AV fistula, aneurysm or pseudoaneurysm [except in the iliacs where 34900 is used]).
Answer: No additional E/M is allowed on this return visit date, and the code billed is: 11102 with work RVU .66
Answer 1: No. When using time to choose your level of service, use only the time you spent on the date of service.
Answer 2: No. The AMA does not require you to provide counseling or coordination of care to choose your procedure code based on the time you spent.
Answer 3: You can still use the time spent face-to-face and for appropriate non-face-to-face activities on the date of the encounter to choose your procedure code. If documenting the service on a different calendar date, do not include the time spent documenting
To learn more about the Coding Corner Membership Options, go to https://www.terryfletcher.net/services/coding-corner-network-membership/
Ever since the release of the new 2021 Evaluation and Management (E/M) guidelines for Office and Other Outpatient Services, ICD10University has been conducting numerous provider and staff educational training sessions through Webcasts, articles, and session spotlights on ICD10Monitor.com’s Talk Ten Tuesday live broadcast and podcast. In this article, we will answer the Top 10 questions we continue to receive from our listeners and clients.
You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E/M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215), only.
The provider is not required to document both total time and MDM (medical decision-making). They can select whether total time or MDM best represents the work performed for each encounter. The provider should level their code based on the best circumstance for the encounter.
Discussed during our most recent EM 2021 Auditing Webcast, we polled our audience on whether providers thought the total time of the encounter or MDM best represented their work and the majority answered MDM. The case studies that were offered, also reflected that MDM was much easier to support higher levels of service than the time threshold.
We recommend that using “time” to level your encounter may be most appropriate for instances when the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions or counseling the patient on the best treatment plan takes an unusually long amount of time.
This is a “Best Practices” case scenario where basing code selection on time may allow you to report a higher-level visit that more accurately represents the provider’s work.
To properly document total time, AMA instructs that the provider needs to document the activities performed and include a statement of the total time for the encounter.
Since you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination performed by ancillary staff), it is recommended that the provider includes a statement that the total time does not include the time spent performing other billable services. (e.g., the skin tag removed from the patient’s right armpit took 16 minutes that was not included in the total time of the visit, and was billed separately).
A frequent question our ICD10University educators have received is if it is required to document the time increments associated with each activity (for example, 5 minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time must be documented.
However, if your encounter is ever audited by a payer, it is recommended that your statement does include specific services with the total time spent to support your time as a qualifying leveling option.
No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E/M code. We are also often asked if you can count resident time.
The answer is “no” as well.
The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching or supervising physician.
If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. For example, your provider orders a chest x-ray and an EKG during the face-to-face encounter, and bills for both of those services. They cannot count towards the Data Points under the MDM nor can you count the time to order or perform those services, as they are “separately reported”. There is no double-dipping.
The AMA’s technical correction (Errata) states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.
Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level.”
What this means is that if your provider reviews an x-ray for example that was taken in the ER and sent over for review by your physician with the patient, and the physician just went over the results with the patient, then you would count this “review of a unique test” under Cat 1 of the Data Points Element.
On the other hand, if this review included a more detailed, documented interpretation of the film by your physician in determining the next step of care, and again, well documented (not necessarily a formal interpretation), then this could be considered under Cat 2 of independent interpretation of a test performed by another provider that you did not separately report.
No. You can count the ordering of the test during the visit when it’s ordered, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order, again AMA considers this double-dipping. It will be a challenge for auditing and CDI staff to determine when the test was ordered and reviewed to make sure credit is given at the appropriate encounter.
This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results, even though at some point the patient will be given the results.
Another typical scenario is the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests because they were ordered after the patient was seen and the order was not counted as data at the previous visit.
No. Per AMA and NAMAS, unless the testing has a direct bearing on “problems addressed” then simply adding or ordering preventative services that do not factor into the MDM of a problem-oriented visit, are not counted or time or MDM elements.
No. CPT® Errata clarified what “discussion” means:
“Discussion: requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange.
The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).”
Now in saying that, the AMA direction for 2021 has been that to include any MDM elements or time elements that the work has to be on the same date as the “face-to-face” encounter; so this seems to be an exception. A little advice here would be to include this exchange if it is on the same date so that the record is not left open to wait for a return call back from the external provider.
No, all the information from the unique source would be counted as one Data Element under Cat 1. This is clarified in the technical corrections released in March 2021 by the AMA: A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.
No. Use of a translator does not count for independent historian since the patient is still giving the history.
However, if using “time” to level your visit, include the extra time it took to use a translator if that factored into a longer encounter. If the provider is the translator and extra time was not needed, then this would have no bearing on MDM or time.
CPT ® AMA Errata – Corrections 2021 5.3.2021
As promised, below is my Modifier 22 Letter to assist in appealing claims: when the procedure or surgery was an “increased procedural service” and the reimbursement on the fee schedule does not account for the extra work, time, and difficulty.
Modifier 22 Letter (PDF Format)
A career as a remote coder allows you to work remotely in the healthcare field and use your computer skills to access what you need to fulfill the job requirements of an onsite coder or billing professional.
Remote medical coders are typically set up through their employer’s/medical practice’s IT department to access the patient medical records remotely and the practice management software for billing and coding. Most tasks are data entry input related, but many remote coders that work outside the healthcare facility, typically from home, have additional tasks beyond the data entry of codes, and some employers do ask that the remote coder be onsite at least 2-4 times a month.
Successful remote coders will need to be attentive and pay close attention to details to avoid making mistakes. For those working from home, who can set their own hours, will also need to be disciplined and focus to stay on track to meet deadlines. The table below gives you and idea of the educational requirements for most remote coders.
|Degree Required||Associates degree common, or coding certification equivalent|
|Education Field of Study||Health Information Technology (HIT), Revenue Cycle Management (RCM) or Professional and/or Facility Coding|
|Certification||Most healthcare employers require a “coding certification” of some kind to prove experience in the field of coding, billing and reimbursement, and health IT**|
|Key Responsibilities||Use ICD-10 and CPT codes corresponding to various diagnoses and procedures and enter them into medical software, keep records, insurance claim submission and follow up.|
|Job Growth (2014-2024)*||15% (for all coding professionals, medical records and health information technicians)|
|Median Salary (2017)*||$37,110 (for all medical records and health information technicians)
$41,500 (for most coding professional remote positions with minimum 3-years experience)
*Source US Labor Statistics
** See below for Certification options
If you want to get “certified” as a coder (there is not a specific certification for remote coders), and I highly recommend you do, there are many options. For hospital facility coders, AHIMA (American Health Information Management Association ~ www.ahima.org ) has several certification options, such as CCS (Certified Coding Specialist), RHIT (Registered Health Information Technician) and CCA (Certified Coding Associate) to name a few.
The AAPC (American Academy of Professional Coders ~ www.aapc.com ) has physician based certifications, also known as “pro fee” coding certifications such as the CPC (Certified Professional Coder) and AAPC offers specialty certifications in areas like, Cardiology (CCC), Interventional Radiology (CIRCC), E/M coding (CEMC) and more. There are other certification options from Board of Medical Specialty Coding (www.medicalspecialtycoding.com), QPro formerly PAHCS (www.QPro.com)
Although the implementation of remote coding can be straightforward and seemingly easy to implement, you need to address a number of issues before sending coders home. These included:
Before implementing a remote coding program, ask ALL of the workers who will be working at home to sign a written telecommuting agreement. This establishes expectations for everyone involved, including managers and coders who will have very little direct supervision. It also establishes what the coders can expect from support and management staff.
The agreement should address issues such as:
If all of these issues are outlined at the start, there will be much less confusion, which will contribute to the program’s overall success.
To recognize and reinforce the importance of the confidentiality of the online record, a separate confidentiality agreement should be developed and incorporated. This document should address the office location within the home, the need for a separate secure location that will not be accessible when the coder is not working, the security of the information on the PC (and a computer that no one in the family has access to), and the need to sign off the application when the coder is not physically in front of his or her PC. Once the employee has reviewed and signed this agreement, there should be no questions regarding expectations about confidentiality and security.
Before implementing a remote coding system, here is a sample of questions to ask:
Being allowed the opportunity to be a remote coder, and not have to commute, deal with weather or traffic, office drama, coming in sick, etc, is a privilege not a right. If you are given the opportunity, it is up to you to respect the process and make sure you have what it takes to be a successful remote healthcare professional.
As the population ages, the need for medical coders is growing. The Bureau of Labor Statistics (BLS) expects this field to grow by 21% through 2020, a rate much higher than an average healthcare industry job. Breaking into the medical coding business is not difficult, especially with the demand for skilled coders so high.
Because coding is such a detail-oriented position and the coder’s work affects nearly every area of a medical practice, a novice coder can be quickly overwhelmed. When beginning a medical coding career, there are several tips to make the job easier and make your work better.
New medical coders often come out of a generalized educational program. This is a good foundation, but if you are working in a specialized practice, such as a radiology firm, or cardiology or orthopedic surgery, you most likely will need to dig deeper to understand some of the subtle coding nuances.
It is common for office procedures to carry multiple codes, and many times the office staff takes for granted that you know what those procedures and codes are. In a training course I was conducting last week, we had both the seasoned coders and the new or potential new coders that were moving from Med Recs to coding, and the seasoned coders had lots of questions on things they already had a point of reference on, but I noticed the new staff had nothing to say. I know part of that silence was because they were taking it all in, but part was because they really didn’t understand the concepts.
Spend time with the practice manager learning about the flow of the office and standard procedures so that you do not miss any codes that could prevent the office from being paid properly.
Pull previous superbills (or the EMR patient ledger) and claim forms for the most standard office procedures to see how they have been coded in the past.
Do not assume the codes are correct; review the procedures done against the medical record and perform a mini-audit to see if you would code the record in the same way. This often gives you a solid idea of normal office flow and procedure. Note any discrepancies and discuss them with the practice manager.
Review all contested or unpaid explanation of benefits (EOBs) to see if a coding error is to blame. Often transposed digits or simple coder error created the problem. Fix the error and resubmit the record for payment.
Discuss large-scale, unpaid EOBs with the billing and office staff to ensure that you are all working as a comprehensive team to get every procedure paid as quickly as possible.
Online access to CPT and ICD-10-CM coding books and materials is often included with your school textbook purchases; keep both the books and any online access codes in a safe place so you can bring them to your job. Having quick, reliable access to these materials will help you save much time and frustration as you are starting a new coding position.
Make these books your own by using highlighters for language within a code, tab areas that you frequent (out of order sequenced codes), make notes alongside a code that you are not familiar with but see often, and little notes to yourself as to remind what is correct and not correct, e.g. (99152 Moderate sedation- Propofol no, Midazolam/Versed yes).
Whatever helps you best understand and remember, do it. It will help you later if you decide to take your certification exam and on the job.
Medical records and health information technicians earned a median annual salary of $38,040 in 2016, according to the U.S. Bureau of Labor Statistics. On the low end, medical records and health information technicians earned a 25th percentile salary of $29,940, meaning 75 percent earned more than this amount. The 75th percentile salary is $49,770, meaning 25 percent earn more.
In 2016, 206,300 people were employed in the U.S. as medical records and health information technicians. Only a fraction of this number had actual “certified” personnel doing the job.
According to a salary survey conducted by the American Association of Professional Coders, the average starting salary for medical coders was around $33,000 per year in 2012 – a figure which hadn’t changed significantly since 2008.
However, the latest round of statistics showed that salaries increased quickly since 2012, and the most recent figure for a starting medical coder in 2016 was $41,000. The same salary survey reveals that coders average about $47,000 after five to nine years on the job and can hit $50,000-$65,000 per year with between 10 and 15 years of experience. Those with over 15 years of experience averaged just over $60,000 per year.
Of course, there are other factors that determine what coders can expect to be paid.
Across the country, the AAPC found that all coders made an average salary of $47,870 per year. However, salaries vary considerably by region. The lowest average salary, $41,709 per year, was reported in the East South Central states.
Those in the West North Central states averaged $44,464 per year, and coders working in the Great Lakes region reported an average salary of $45,258. The highest-paying regions for this occupation were New England, at $51,382; the mid-Atlantic, at $52,505; and the Pacific region, at $56,980.
As of 2013, the AAPC reported that coders who do not have a college degree earned an average of $41,066 per year. Those who held a postsecondary certificate aka coding certification or associate’s degree – who made up over half of all respondents — reported an average salary of $45,941 per year. Those who held a bachelor’s degree earned substantially more at an average of $54,266.
Coders who held a master’s degree out-earned all other categories of education, with an average annual salary of $79,405. But to be fair, coders in those positions were either in administrative positions, consulting positions, had not only multiple certifications in coding but also at least 10-years experience.
According to the Bureau of Labor Statistics, job prospects for medical coders, medical billers and other health information technicians should be good through 2020. The bureau expects these jobs to grow at a rate of 21 percent, 11% higher than the average growth rate for the American economy. However, the AAPC found that about 23 percent of those holding entry-level credentials reported struggling to find a job in 2016.
Remember, the job does not come to you. You go to it. How do you do that? Start cold calling practices. I know it is the most glamorous way to grab that coding job, but some practices just do not have the time to post a job on Monster, or on a job fair website. Also, those sites tend to weed out good candidates, since they only assess what is on paper. Next, put yourself out there.
Take in-person coding workshops to network, go to AAPC and AHIMA chapter meetings and network, choose to start in a different department (billing or medical records or even front desk) and then work your way into the coding position. Once the practice sees you are overqualified for your position, you could open a window to move up, or you could decide you like a different branch of the medical office position.
Lastly, especially on social media, be smart. Complaining about your lack of job or how a certification entity hasn’t helped you only gets you noticed as a complainer that is waiting for that big break. It also shows a potential employer you have limited skills of propriety.
You don’t think physician practices and hospitals are looking at LinkedIn, Twitter, Facebook or Instagram? Think again.
I love Instagram, and Twitter, and have had more business generated through social media reach than ever before. Also, write articles and write a lot. A published author opens so many doors for employment because you now have name recognition. Write about what you know. AAPC, AHIMA, Advantage Health to name a few, are always looking for accomplished writers on the topic of healthcare. Oh and grammar counts.
Everyone has to start somewhere. There is no elevator to the top floor coming off of a new certification or a decision to be a coder. But you can do it if you have the right mindset and the right understanding of what it takes. Good Luck!