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Medicare Launches Initiative for Documentation Look-Up Tool

Medicare recently announced a plan to streamline the process of finding coverage and documentation requirements for applicable services. Currently, documentation requirements appear in various locations and on separate websites requiring physicians and staff to navigate multiple websites for information.

The first step in the initiative is the development of a pilot program for a Medicare Fee-For-Service Documentation Requirement Lookup Service. The prototype look-up will include a list of items/services for which prior authorization is required. CMS is participating in private and government industry workgroups to develop standards for the Look-Up tool.

The goal is for providers to access prior authorization and documentation requirements at the time of service and within the electronic health record or integrated practice management system. Medicare is also encouraging all payers to consider similar approaches to streamline workflow access to coverage documents. This is one of several initiatives being taken by CMS to reduce provider burden.

Visit the CMS website for more information on this initiative and other Medicare Fee-For-Service Compliance Programs. 

E/M Services and Procedures on the Same Day: When Can You Report Both?

According to CPT, both an Evaluation and Management (E/M) service and a procedure code can be reported if the patient’s condition requires a significant, separately identifiable E/M service. “Significant” implies that the E/M service required some level of history, exam and/or medical decision-making. “Separately identifiable” suggests that the visit is distinct from the procedure. In other words, the E/M service should be above and beyond the pre- and post-procedure care typically provided. Therefore, simple confirmation of symptoms, explanation of the procedure, signing of consents, and verification of medical information are typically considered inherent in the procedure code and were considered in the value of the procedure.

CPT does not require there be different diagnoses for the E/M service and the procedure to report both codes. After an initial evaluation of a patient presenting with back pain, a decision may be made to proceed with a pain intervention procedure. The same diagnosis would likely apply to the E/M Service and the procedure code. In other situations, the visit might be prompted by a condition unrelated to the procedure. For example, a patient presents for a lumbar epidural steroid injection, but also asks you to evaluate his shoulder pain. You would therefore report both diagnoses, but link each CPT code to the applicable diagnosis code(s) on the insurance claim form.

In general, you report both the E/M service and the procedure if:

  • An evaluation and initial decision to perform the procedure was made at the same encounter as the procedure, regardless of the diagnosis, or
  • The diagnosis for the E/M service was different from the one for the procedure.

Generally, report only the procedure if:

  • The decision to perform the procedure was made at another visit, or
  • The E/M service did not require a medically necessary significant history, a physical and/or decision-making on the day the procedure was performed.

When reporting both services, the modifier 25 must be appended to the E/M code to confirm that distinct services were performed. CPT states that a significant, separately identifiable E/M is “defined or substantiated” by documentation that satisfies the relevant criteria for the E/M service. Therefore, it is important to clearly document a distinct visit when reporting a procedure on the same day.

CPT and Medicare have similar rules governing the reporting of visits on the same day as a procedure. Although many third-party payers follow CPT guidelines, others may have their own guidelines based on internal payment policies. It is important to remember that following proper coding rules does not guarantee reimbursement.

E/M Services and Procedures on the Same Day: When Can You Report Both?

According to CPT, both an Evaluation and Management (E/M) service and a procedure code can be reported if the patient’s condition requires a significant, separately identifiable E/M service. “Significant” implies that the E/M service required some level of history, exam and/or medical decision-making. “Separately identifiable” suggests that the visit is distinct from the procedure. In other words, the E/M service should be above and beyond the pre- and post-procedure care typically provided. Therefore, simple confirmation of symptoms, explanation of the procedure, signing of consents, and verification of medical information are typically considered inherent in the procedure code and were considered in the value of the procedure.

CPT does not require there be different diagnoses for the E/M service and the procedure to report both codes. After an initial evaluation of a patient presenting with back pain, a decision may be made to proceed with a pain intervention procedure. The same diagnosis would likely apply to the E/M Service and the procedure code. In other situations, the visit might be prompted by a condition unrelated to the procedure. For example, a patient presents for a lumbar epidural steroid injection, but also asks you to evaluate his shoulder pain. You would therefore report both diagnoses, but link each CPT code to the applicable diagnosis code(s) on the insurance claim form.

In general, you report both the E/M service and the procedure if:

E/M Services and Procedures on the Same Day: When Can You Report Both?

According to CPT, both an Evaluation and Management (E/M) service and a procedure code can be reported if the patient’s condition requires a significant, separately identifiable E/M service. “Significant” implies that the E/M service required some level of history, exam and/or medical decision-making. “Separately identifiable” suggests that the visit is distinct from the procedure. In other words, the E/M service should be above and beyond the pre- and post-procedure care typically provided. Therefore, simple confirmation of symptoms, explanation of the procedure, signing of consents, and verification of medical information are typically considered inherent in the procedure code and were considered in the value of the procedure.

CPT does not require there be different diagnoses for the E/M service and the procedure to report both codes. After an initial evaluation of a patient presenting with back pain, a decision may be made to proceed with a pain intervention procedure. The same diagnosis would likely apply to the E/M Service and the procedure code. In other situations, the visit might be prompted by a condition unrelated to the procedure. For example, a patient presents for a lumbar epidural steroid injection, but also asks you to evaluate his shoulder pain. You would therefore report both diagnoses, but link each CPT code to the applicable diagnosis code(s) on the insurance claim form.

In general, you report both the E/M service and the procedure if:

  • An evaluation and initial decision to perform the procedure was made at the same encounter as the procedure, regardless of the diagnosis, or
  • The diagnosis for the E/M service was different from the one for the procedure.

Generally, report only the procedure if:

New Part D Opioid Overutilization Policies

CMS implemented new opioid policies for Medicare drug plans effective January 1, 2019. Medicare Part D enrollees who have not filled an opioid prescription recently (within the last 60 days) will be limited to up to a 7-day supply. The limit does not apply to those already on opioids. The new guidelines are not prescribing limits and are meant to encourage collaboration and care coordination among Medicare drug plans, pharmacies, prescribers, and patients to avoid opioid misuse.

In conjunction with the new policies, CMS sent information letters to physicians and have created several training documents and resources for physicians, pharmacists and patients. View the prescribers guide to the Medicare Part D Opioid Overutilization Policies for 2019.

Additional information can be found at CMS.

Opioid Treatment Agreement and Prescription Drug Monitoring Program-New Bonus Points for MIPS

Two new bonus measures have been added to the Promoting Interoperability (PI) category in the MIPS (Merit-Based Incentive Payment System) program for 2019. The new measures are not required and do not contribute to the measure score but they do contribute 5 bonus points each. Both bonus measures can easily be achieved by most Pain Medicine Physicians. The measures are under the e-prescribing objective and read as follows:

  • Query of Prescription Drug Monitoring Program (PDMP)

For at least one Schedule II opioid electronically prescribed using CEHRT (certified electronic health record technology) during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.

  • Verify Opioid Treatment Agreement 

For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.

For 2019, both the reporting and scoring under the PI category has been simplified. There is a single measure set which includes new and existing PI performance category measures organized under 4 objectives. Measures are no longer classified as base score or performance score measures. Each measure will be scored by multiplying the performance rate by the available points for the measure. The PI comprises 25% of the total MIPs score.

A full-understanding of requirements and reporting methodologies can be found here.

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American Academy of Pain Medicine