Coding Challenges in Geriatrics
By Elizabeth S. Roop
Accurate documentation is key to proper geriatric coding that ensures Medicare authorization and allows prompt reimbursement.
Compliant and accurate coding backed by comprehensive clinical documentation is crucial for ensuring physicians receive the highest level of reimbursement to which they are entitled. Erroneous coding can delay payments, negatively impacting cash flow as payers withhold reimbursement until bills are corrected or appropriate supporting documentation is received.
For providers who care primarily for older patients, the process is even more complex due to stringent Medicare regulations and idiosyncrasies specific to each care environment that impact the coding and documentation required for reimbursement.
Traditional Ambulatory Settings
“Many tests or procedures may be performed in the clinic, and Medicare is likely to ‘bundle’ and reduce payment unless medical necessity is met. [Therefore] coders must utilize documentation guidelines for coding and meet typical auditing standards,” says Gwenmarie Goodale, a medical billing and insurance coding instructor with the Everest Institute.
In many cases, failure to use the correct bundle can result in denial of payment. In other instances, using individual rather than bundled codes can reduce reimbursement rates, as the latter typically reflects higher severity.
More often than not, these coding issues can be resolved with improved clinical documentation. The reality is that comprehensive documentation on the front end drives accurate and compliant coding and billing on the back end. When a coder must seek additional information to determine whether a higher-level code is warranted, it delays billing and slows the overall revenue cycle. Conversely, if documentation is insufficient to support a higher-severity code, the claim is likely to be denied or care billed at a lower reimbursement level. It can also impact whether or not the payer considers the care medically necessary.
“The efficiency of coding and billing is the efficiency of documentation. There are physicians who are good documenters and those who are not. As we move into ICD-10 and healthcare reform, we’re going to find out that documentation is key,” says April Borgstedt, CHC, CPMA, CPC, CPC-I, CEMC, CCA, FSA, CMC, a senior compliance specialist with Cancer Treatment Centers of America, a national network of hospitals providing a comprehensive, fully integrative approach to cancer treatment. “If you’re not doing it right the first time, you’re going to lose money and may put the business as a whole at risk if operating in a solo practice.”
This is true particularly for those practices and facilities that have not yet made the leap to electronic documentation and coding systems. Not only will the transition to the vastly expanded ICD-10 code set be far more laborious and costly for these practices, but paper-based documentation and coding systems are highly prone to human error that can wreak havoc on the bottom line.
It could be as simple as using the wrong patient Medicare provider number, which means the physician won’t get paid. Or it could involve using an incorrect referral code, preventing a Medicaid patient from getting the oxygen cape or cane the physician ordered. “If you’re still relying on paper when the rest of the world is electronic, expect a higher rate of coding and billing error, in part due to poor interpretation of handwritten physician documentation,” says Borgstedt. “There is also a higher risk of misplacing records, and the electronic world offers options to digitally communicate with patients and providers.”
Home Healthcare Challenges
“That standardized data-gathering tool drives the plan of care for the patient, the coding and sequencing, and thus the reimbursement,” Hebert says. “The challenge is the skill of each clinician, which can impact the assessment of the environment, severity of illness, ability to communicate, etc. We’re always dealing with a moving target when dealing with a patient at home.”
However, documentation for care plans and oversight is not the greatest challenge for home health providers and the physicians with whom they work. According to Hebert, the most significant challenge lies in compliance with two new regulations from the Centers for Medicare & Medicaid Services (CMS).
The first is a requirement for documentation of a face-to-face encounter with a physician or a nurse practitioner prior to admission of a Medicare beneficiary to home care. This applies to patients referred by hospitalists as well as by physicians from all inpatient settings, such as rehab facilities and skilled nursing facilities (SNFs).
“That might not sound as it if it would be an obstacle because you generally would think that a patient has seen a physician prior to home care. The real issue is documenting the encounter, the date, and the reason for the visit,” Hebert says.
The reason behind this new regulation, tied to recently enacted healthcare reform, is ensuring that the postacute order is for the same or similar diagnosis as that for which the physician has seen the patient on his or her previous visit. The idea is to be able to link together coding for the hospital, physician visit, and home care.
“It is grand in the scheme of things, but there is no way to track it through CMS,” says Hebert, noting that the industry was given a reprieve on the face-to-face encounters, enforcement of which was set to begin April 1. “We [had] through the first quarter of 2011 to put processes in place. CMS [was] responsible for going out and training physicians on how to document these face-to-face encounters.”
The second regulation expected to cause documentation, and therefore billing headaches, calls for physicians to personally sign and date all orders for a patient’s care before a claim can be filed with Medicare for reimbursement. In the past, when undated documents were received from physicians, intermediaries had been permitted to date stamp them to show when they were received by the home health provider. “The change will cause additional workflow for physicians because we must return paperwork back to their office for dating,” says Hebert.
But this is a process unlikely to be streamlined through technology. Hebert notes that while most home care agencies have some information management systems, such as point-of-care documentation devices, only about 20% of physicians nationwide use any kind of portal to electronically sign the care documentation those systems produce. “So the majority of what they sign for us actually has to cross their desks,” says Hebert. “It’s a workflow problem and huge volumes of paper.”
SNFs, ALFs, and Hospice
The most significant challenge in these settings lies in understanding how Medicare reimburses for care provided. Like ambulatory care, which codes and bills based on diagnosis and treatment, there are edits for SNFs that establish limitations on services based on a diagnosis in combination with a procedure or a service code. “Those limitations can be for daily services, across a month, or a limitation or guideline that’s recommended for a certain type of service, such as physical therapy or occupational therapy, for an annual benefit period. So understanding the benefits their patients can receive is important,” says Melissa Farugia, a care and reimbursement specialist with Touchstone Communities, which provides healthcare services, including skilled nursing, rehabilitation, Alzheimer’s care, and assisted living.
Attempting to bill for services that fall outside the established limitations or guidelines will result in denial or delayed payment while the claim is corrected. What makes coding and billing for care in this setting even more challenging is that those delays impact not only the physician submitting the claim, but can also impact any other physician or provider who is part of that patient’s care team.
“There are certain databases within Medicare where services are coordinated between providers, so it’s very important that billing is done in a timely manner,” says Farugia. “If a service is provided more quickly, billed, and submitted more quickly, the more updated that system is for others who need to coordinate care.”
Those databases also come into play with undercoding, another common coding problem in the SNF/ALF environments. When a less specific code is used, it reduces the severity and therefore the reimbursement level. It also impacts authorization and reimbursement for any future care provided for that diagnosis by any physician or provider on that patient’s care team.
“As they’re documenting in the medical record, it moves into the billing system, and that’s what goes into the [Medicare] provider database,” says Brad Talley, vice president of reimbursement services for Touchstone.
“If we’re not being as specific as we need to be on the coding, it can delay the billing process, which also delays the updating of the total system for every provider out there,” Farugia adds. “So not being as specific as we need to be can actually delay that [updating] process.”
Physician services rendered to hospice patients produce yet another challenge in terms of coding and billing. Expenses for most services provided for hospice care are bundled and paid under a consolidated billing system. Hospice enrollment requires a physician to certify that a patient has a terminal condition supported by a medically appropriate and necessary plan for palliative care.
“The problem is that not all conditions or services are related to the hospice care plan; therefore, in these situations, a physician deserves additional reimbursement,” says Borgstedt. “Physicians and support staff need to have solid working relationships with the [hospice agency and/or ALF] as well as have coders savvy enough to recognize this is a hospice situation and apply the appropriate modifier.”
Technology and Education
According to Farugia, the best way to prevent situations such as undercoding “is making sure that we are educating our caregivers to be as specific as possible when using diagnosis coding. It starts with great communication and great training and education for the office staff and the physicians themselves.”
Education will be particularly important as the industry moves closer to the final transition to ICD-10. In addition to the costs of a new system, extensive training of coders and physicians on the expanded code set will be required.
“It’s too early for providers to focus on learning ICD-10 codes, but they do need to have a team dedicated and working on a plan for ICD-10 implementation and begin beefing up documentation to include more detail,” says Borgstedt. “It’s the documentation details that impact coding and reimbursement the most.”
Electronic documentation and coding systems can reduce human errors as well as under- or overcoding that can lead to denials or delays. Many will integrate directly into electronic medical record systems that can be accessed by a patient’s care team via interfaces or portals to ensure that the care ordered is medically necessary and therefore reimbursable.
However, for those practices that aren’t ready to make the full conversion to an electronic environment, working with a service that provides electronic data capture and entry, and claim and transactional data submission to payers, can eliminate many coding errors that delay or reduce reimbursements.
For a monthly fee, these services eliminate the paper processing between physicians’ offices and payers. Coding is handled at the practice and submitted to the vendor for validation and submission to the insurance company.
“If a claim is rejected on a basic level, such as a missing field or it should be alpha-numeric, we get it back to the practice in real time for correction,” says Bill Bartzak, president, CEO, and founder of MD On-Line, Inc. “If it’s rejected by the insurance company, it takes 24 hours. To us, payments are what is important, and that means that our clients get paid in anywhere from three to seven days rather than 45 days.
“It all starts with the person putting the information into the system,” Bartzak says. “You need to make sure the right information is inputted the first time. When claims are rejected, it’s largely due to human error. There is even a bigger problem coming down the road with ICD-10. It literally is a trillion-dollar training program to bring these offices up to speed.”
— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.
Medicare: A Regulatory Minefield
“An important recent rule from the Affordable Care Act [ACA] places new mandates on reporting overpayments stemming from Stark Law violations, of which geriatric physicians should be aware,” says Richard Wagner, a Chicago-based healthcare attorney and managing director of Wagner Healthcare Consulting, LLC, which advises healthcare professionals on regulatory compliance issues. “Generally speaking, the ACA now requires quick reporting and remitting of overpayments back to CMS [the Centers for Medicare & Medicaid Services] in time frames as short as 60 days. However, new self-disclosure rules allow providers that swiftly notify the government of potential Stark violations to suspend the ticking clock. Other benefits may include reduced penalties and/or protection from whistle-blowing lawsuits.”
The catch is that self-disclosure is not always in a provider’s best interest. The intent behind the self-disclosure protocol was to encourage providers who violate antikickback laws, receive overpayments, or otherwise commit fraud and abuse to self-report to the Office of the Inspector General (OIG) in return for reduced penalties. However, if the violation is of the Stark law, it cannot be self-reported to the OIG.
“So in the ACA, CMS was mandated to come out with Stark-only self-disclosure protocols. Providers were hoping penalties would be more lenient and would differentiate between big issue problems and paper liabilities. The AHA [American Hospital Association] wrote a memo to CMS proposing these guidelines, but when CMS put out its final regulations, it effectively ignored the AHA recommendations,” says Wagner. As a result, many providers are stuck between a rock and a hard place. “Do I submit and have all this potential liability or criminally conceal? That’s a tough decision,” he says.
The other concern is just how wide-ranging the Stark law is, in particular when it comes to so-called paper violations. These include items such as unsigned contracts, holdout tenants in leased spaces or in some cases, a physician leasing space from a hospital. Even in cases where contracts are legally completed, there could still be a Stark violation in some context of the terms. It’s a serious concern, particularly as accountable care organizations begin to emerge with no regulatory safe harbors to protect physicians and hospitals that may be joining forces in the organizations.
“If there is a Stark violation, you would have to account for every single Medicare payment that was directed through that relationship. Every single patient you saw is subject to overpayment and could be recoupable. These could potentially be very huge civil monetary penalties,” says Wagner.
“The key here is prevention,” he adds. “Geriatric physicians who are familiar with the new regulations and have proper compliance programs in place will be able to bill more efficiently without worry of stepping onto a regulatory landmine. The alternative—expulsion from the Medicare program—is not an option.”
Coding and Billing in the LTC Environment
For starters, coding is typically not procedure driven. Rather, an LTC facility evaluates a resident based on the care needed, including therapy and other ancillary services. The facility is then reimbursed based on the pay source. For Medicare, payment is based on the patient’s Resource Utilization Group (RUG) score, while Medicaid is based on a set facility-specific per diem. For other payers, reimbursement is based on a negotiated rate or a percentage of charges.
“We are a little different in that diagnosis is part of the process, but it doesn’t drive reimbursements,” says Roseanne Reynolds, director of patient accounting for Trinity Senior Living Communities. Instead, reimbursement in the LTC environment is based on the care needs of its residents. For residents in a Medicare and/or Medicaid-certified facility based on the Minimum Data Set (MDS), a standardized primary screening and assessment tool of health status forms the foundation of the comprehensive assessment and drives the care plan for a patient’s stay.
One of the most significant challenges LTC providers faced was CMS’ radical overhaul of the MDS RUG system. “It touched on everything we do. Modifiers changed and we had to make sure payer systems had changed too. Fortunately, we stayed on top and did a lot of planning, so we were able to manage the big shift,” says Reynolds.
One ongoing challenge LTC providers face with Medicare beneficiaries is the frequency with which they opt out of traditional Medicare and move into a managed Medicare program without informing the facility. “That’s a pretty big deal for us, so we’ve had to put some processes in place, such as proactively checking the Medicare system to make sure people haven’t discontinued traditional Medicare,” says Reynolds. “It’s important because sometimes Medicare HMOs require preauthorization, so we have to get that retroactively.”
Also unique to LTC is that, unlike most other sectors of geriatric care, Medicare is not its biggest payer. That is partially because the Medicare LTC benefit is extremely limited and quickly exhausted. When that happens, many residents must go through the complex process of qualifying for Medicaid that typically involves meeting state-specific requirements that examine both financial and clinical status.
LTC facilities also deal regularly with private LTC insurance. When taken as a whole, the one certainty in LTC reimbursement is that regulations and processes will change. That is why Reynolds says it’s important to “be as proactive as you can in any way that you can to plan for some of these big changes. I’m lucky in that I’m surrounded by experts in their own areas, so we work as a team to stay on top of every aspect, whether it’s billing for reimbursement or clinical. A lot of times, individually owned nursing homes don’t have the experts they can ask, so it’s very time consuming to manage these big changes.”