NUTS AND BOLTS OF CODING FOR AN ALLERGY PRACTICE

Diagnosis Coding

• The diagnoses need to be specific – ICD-10 is here in 2014
• Remember place the diagnosis with the most acuity first
• Acute precedes chronic
• Co-morbidities – you need to address how the comorbidity affect the allergy/asthma issues
• List the co-morbidities after your dx
• If you code it make sure it is in the documentation
• Medical necessity is defined with diagnosis codes

Chart Auditing –How to analyze your chart notes 

• Chief Complaint – make sure your note leads the reader down the appropriate path
• CC – “Patient is here for retesting for allergies”
• HPI – Make sure your HPI is for today’s encounter.
• HPI – Make sure it is clear what information is for today.

Previous information is ok but only for your information.

• HPI – The provider is required to obtain the information for the HPI.
• Past, family and social history – make sure it is applicable to the patient for your questions.
• ROS – if the patient is filling out the information or your staff, make sure there is documentation to support the providers review of the information obtained.

Chart Auditing –How to analyze your chart notes

• Exam – 2013 tell the reader what you see
• Normal is ok but describe – templates
• Make sure templates match the rest of the note for complaints
• You may use either the allergy specific or the general medical exam (1995 or 1997 guidelines)

Difference between a 99204 and a 99205

• 99204 99205
• Comprehensive hx Comprehensive hx
• Comprehensive exam Comprehensive exam

Moderate Medical Decision making (need two at same level or higher)

• Number of Diagnosis 3 or more
• Amount of Data 3 or more
• Lab
• Radiographs
• Medical records
• Medicine tests not billed
•  Risk
•  Moderate: Prescription drug management, undiagnosed new problem, one or more chronic conditions with mild exacerbation, progression or side effects of treatment

High Medical Decision Making need two at the same level or higher

• Number of diagnosis 4 or more
• Amount of data 4 or more
• Risk
• High:
•  Drug therapy requiring intensive monitoring for toxicity
•  One or more chronic illness with severe exacerbation, progression or side effects of treatment
•  Acute or chronic illness or injuries that pose a threat to life or bodily function

Ancillary services

• Allergy testing
• Interpret the test because the code includes interpretation and report as part of the code.
• Have name and/or initials of the supervising provider on the test
• Nebulizer treatments, MDI instruction
• Separate document
• CT Scans, radiographs
• If billing for it as a separate service, there should be a report as a separate document in the chart.
• Scopes
• Separate procedure note

Ancillary Services

• Immunotherapy – make sure billings for CMS are per cc – limit per billing are 10 cc’s
• Make sure there is documentation of the “recipes” for each patient.
• Document on the allergy injection record the beginning of a new vial.
• Document review of allergy injection record.
• If more than “normal” number of injections, make sure medical record supports the necessity of the higher number of vials manufactured.

Medical decision cheat sheet 99213

1. Two diagnosis doing well on RX – allergic rhinitis and asthma; allergic rhinitis and conjunctivitis

2. one diagnosis worse on RX – dermatitis not responding

Medical Decision making cheat sheet 99214

• Three diagnosis doing well – allergic rhinitis, asthma, anaphalysis to foods; or allergic rhinitis, asthma, dermatitis
• One new problem requiring an RX - urticaria requiring a RX
• One diagnosis doing well and one diagnosis not responding or worse. Both diagnoses are RX treatment – allergic rhinitis worse, asthma stable Medical decision making cheat sheet 99215
• New problem – pt acutely ill and needs labs, radiology studies, review of chart notes consultation with another health care provider. OR pt presents with additional workup planned and is high risk – 

Time

• Time is appropriate if more than 50% is counseling and coordination or care
• Document total face to face time
• Percentage is greater than 50% of the encounter
• Document the discussion with the patient.

CONSULT-HOSPITAL 99251 99252 99253 99254 99255

CONSULT-3 of 3 99241 99242 99243 99244 99245

NEW CPT- 3 of 3 99201 99202 99203 99204 99205

Allergy practices and Audits

• Number of Test performed
• Number of Doses charged
• Medical Necessity for allergy testing and an E/M on the same calendar date
• Incident to services with mid levels

Incident To Guidelines

• Applicable to ALL government entities – medicare, medicaid, Champus, Federal employees ---
• Incident to - physician has established a plan of care for an employee to follow.
• Physician must be on site when the service is provided
• NP, PA may not supervise diagnostic test under incident to guidelines and bill the service under the physician. 

OIG Work plan for 2012-2013

1. Non-compliance with assignment guidelines
2. Incident to services
3. Place of Service errors
4. Evaluation and Management codes based on 2010 payments
5. E/M with modifiers
6. Claims with G modifiers
7. Payments for physician administered drugs and biologics
8. Medicare as a secondary payer

• RAC Reviews and Audits
• RAC scope includes pre-payment fraud, waste and abuse efforts not limited to credit balance audits, incorrect billing and processing errors, and lack of medical necessity.
• Post payment RAC work includes data mining, medical records review, identifying overpayments
• RAC Reviews and Audits – Connelly Consulting
• Incorrect billing of Evaluation and Management Claims
• Physician Evaluation and Management Services During Same Day Global Period
• Place of Service Errors for Physician claims for service performed in an ASC or outpatient Hospital
• Place of Service Errors for Physician claims for service performed in

Hospital Inpatient setting

• Duplicate Claims - Physician (Carrier) CMS
• Modifier 59 – Know when you can use it appropriately

*  Excessive Units-Untimed Codes  RAC and other payer audits

• Focusing on allergy doses and testing
• E/M on the same date as a testing –
• Some allergist have been reviewed back for three years from Medicaid or Medicare.
• Blue Cross in some states has reviewed most all allergists for E/M on the same day
• United is not paying in some states for E/M and testing on the same date unless notes are submitted.

ALLERGIST CODING CURVE National National

• 99201 -  .47 %    / 99241 - .52 %
• 99202 -  5.00 %  / 99242 - 3.48 %
• 99203 -  30.15% / 99243 - 30.42%
• 99204 -  51.32% / 99244 - 54.02%
• 99205 - 13.06%  / 99245 - 11.56%

ALLERGIST CODING CURVE

• National
• 99211 - 3.98 %
• 99212 - 6.77%
• 99213 - 55.25%
• 99214 - 31.09%
• 99215 - 2.91 %

Audit Response

• Know your risk
• Seek counsel if you are high risk
• Review your records
• Have a third set of unbiased eyes read the notes
• Respond in a timely manner
• Communicate with the payer performing the review.
• Negotiate

Frustrated with Billing and Tracking Issues - Practice Gets a Needed Shot in the Arm with Allergy EHR

Case Study: North Texas Allergy & Asthma Associates

The Situation: Plagued by Inadequate Billing and Document Management in Their Existing System 

North Texas Allergy & Asthma Associates was founded in 1927, making them one of the oldest allergy practices in the country. The practice was founded by Dr. Harvey Black, a president of the American Society of Clinical Pathology and co-author of the textbook “Practice of Allergy.” 

As a busy practice, seeing more than 4,000 patients, they were no stranger to technology. They had a practice management system in place for approximately 6 years, but they soon found that it didn’t integrate with electronic medical records or allergy shot systems. 

They’d grown tired of having to step out of the exam room each time they needed to view shot records. They knew it was time for a change.

Additionally, the practice was dealing with other document management challenges. With two office locations in Plano and Dallas, faxing data between the two in order to track patients was a major hassle and manually storing and tracking that information was completely inefficient. 

Plus, when they were out of the office, they couldn’t access any of their data from home if it was needed - yet another big inconvenience. Their overall practice efficiency needed a shot in the arm.

The Solution: Superior Billing and Well Designed Shot Records

After researching a number of other systems on the market, North Texas Allergy & Asthma Associates found that AllergyEHR, from Meditab Software - a fully integrated scheduling, EHR, billing and immunotherapy solution - offered everything they were looking for.

“Meditab’s superior billing was one of the main reasons we switched over. Our payment of claims and rejections were all pretty messed up.”

Another factor in their decision to choose AllergyEHR was the dedicated support resources. In fact, after using the system for a while now, the comprehensive product support they received has been described by the practice as one of “the most appreciated parts of AllergyEHR.” 

They know that they can access support resources when they need them - online or on the phone and that the team answering their inquiries has the experience to talk them through whatever challenges they may be facing.

The Outcome: A Seamlessly Integrated Billing and Clinical Solution

By switching to AllergyEHR, North Texas Allergy & Asthma Associates has turned the page in a new chapter of their 86 year history. For the past two years, they have been a paperless practice!

With access to tools that give them complete patient information at the click of a mouse, the practice has been able to offer improved quality of care to their patients. 

Now that they’ve replaced manual patient record processes with electronic records, they can easily track and update patient data as required. No more tracking down faxes of lab reports from one location to the next.

Providers can also securely access patient charts from home in case of on-call situations or emergencies. Everything they need to know about a patient is accessible to them online. This has led to not only a better overall experience for their patients, but also a better quality of life for the providers.

Throughout the practice - from front office, to back office and everywhere in between, they have experienced improved workflows and overall gains in efficiency. 

They have seen “more efficiency, fewer rejections, more money and more success collecting claims,” resulting in higher revenue and an improved bottom line.

The streamlined shot lab has also enabled them to save tremendous amounts of time and better manage their shot processes. No more running in and out of the exam room to access and update shot records. It’s all done via a single electronic patient record and with only a few clicks. They save time per visit meaning they can see more patients and their patients have shorter wait times - it’s a win-win!

One of the oldest practices in the country has gone fully electronic, putting all of the headaches caused by paper processes and manual document management behind them. Based on the comments from the North Texas Allergy them take the next steps in their quest to continue providing patients with great care and a positive experience.

About Meditab

Established in 1998, Meditab Software Inc., developers of IMS (Intelligent Medical Software), overs clinical automation systems that maximize productivity, advance patient care, manage utilization, and reduce costs. 

Meditab develops and supports a multi-award-winning, multicer ctronic Health Records (EHR) system that combines clinical charting, e-prescribing, population management, decision support, practice analytics, document imaging and much more, on a single database platform. 

The company takes tremendous pride inproviding comprehensive, user-friendly, and a ordable solutions for each practice’s unique needs.  Time tested and proven, IMS generates tangible returns for medical practices of all sizes. Headquartered in Oakland, Califor ross the globe, Meditab supports hundreds-of-thousands of users nationwide.

Benefits experienced:

1. Increased revenues
2. Received Meaningful Use incentives
3. Completely paperless for the past two years
4. Time saved by completing patient interaction withouthaving to leave the room
5. Improved efficiency with labs