Can I get paid to sign the home health certification form?

CMS pays a small fee for the planning, certification, supervision and re-certification of home health services.  Don’t do the work and forget to get paid. Click the link below to watch this brief video about getting paid to sign the home health certification form.

Can I get paid to sign the home health certification form

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End confusion about modifier -57 (and get paid for initial evaluations)

Recently I completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.

Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier-57 not modifier -25. Why? Modifier-25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure. A minor procedure is defined by Medicare––and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day on the next calendar day, append modifier -57 to the E/M service.

Key points to remember:

  • Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
  • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
  • Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
  • Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.




CMS Updates, TCM, CCM and ACP

At CMS’s Open Door Forum on April 13, 2016 CMS noted there were updates to the Frequently Asked Questions documents for Transitional Care Management, Chronic Care Management and Advance Care Planning. The CMS staff discussed these and answered questions about them. I’ve written about all three topics on this blog, and you can read about them in more detail. At the end of this article, I’ve attached the links to the CMS documents. I strongly recommend that you download and read these three resources. Here are some highlights.

TCM: CMS affirmed that a practice may bill for TCM on the day of the face-to-face visit, without waiting for the 30 day period to pass. Use the place of service in which the visit took place. The biggest change? CMS is following CPT rules about attempting (but failing) to have phone or other direct contact in two business days from the date of discharge. “If two or more separate attempts are made in a timely manner and documented in the medical record, but are unsuccessful, and if all other TCM criteria are met, the service may be reported. We emphasize, however, that we expect attempts to communicate to continue until they are successful, and TCM cannot be billed if the face-to-face visit is not furnished within the required timeframe.”

TCM and CCM in the same month: It is possible to report TCM services in the same month as CCM if and only if a) the 30 day TCM period ends before the end of the month, and b) 20 minutes of CCM time is provided between the end of the TCM service and the end of the calendar month.

CCM: In order to report CCM, individuals who are providing the 20 minutes CCM time need access to the patient’s medical record. However, CMS has clarified in this new document that the access must be to the care plan, not the entire record. “This article alerts providers that the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Learning Network® Fact Sheet on CCM services (ICN 909188, released in March 2015) to clarify Medicare’s requirement for 24/7 access by individuals furnishing CCM services to the electronic care plan rather than the entire medical record.”

CMS continues to defer to CPT in the definition of clinical staff, and to refer to the Medicare Benefit Policy Manual for incident to guidance. Supervision of staff for CCM and TCM is general, not direct. That is, the physician or other billing provider does not have to be in the suite of offices when the service is performed.

A practice may bill for CCM on the date the twenty minutes in the month is achieved. The practice doesn’t have to wait until the end of the month to report CCM.

Advance Care Planning: 99497 and 99498 are time based codes, and CMS has affirmed that they follow CPT time rules. That is, in order to bill the code you need to have reached over half of the time listed in the code. To report 99497, the provider must have spent 16 minutes with the patient; to report 99498 the provider must have spent 46 minutes. CMS affirmed that this can be done by as a team service, if the physician or non-physician practitioner start the discussion with the patient. This does not mean medical assistant! But, a social worker or someone with palliative care experience could work with the patient in addition to the physician. CMS is clear that this is a provider service.

If you are performing these services, or thinking of performing them in your office, download and read the articles. They consist of frequently asked questions Medicare has received about these services. If you have a question, there is a good chance it is asked and answered in these three documents.





Chronic Care Management: new CPT and CMS benefit code for 2015


In the 2015 Final Physician Fee Schedule released on Halloween (CMS loves holiday releases of rules) CMS continues to state its support for primary care. One of the methods: a new benefit, chronic care management (CCM) for which they are proposing a rate of about $40 for 20 minutes or more of this non-face-to-face service during a calendar month. We knew about this from the proposed rule but were in wait and see mode until the final rule came out.

Here’s a surprise! CMS is going to use a CPT code instead of developing a HCPCS code to describe the service. In the proposed rule they stated their intention of developing a HCPCS code but they’ve changed their minds. This means that practices can learn about this code right in a resource that is sitting on their shelves. I hope everyone reading this has their 2015 CPT code on the desk right now.

The new CPT code is 99490: chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
• chronic conditions placed the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
• comprehensive Care plan established, implemented, revised, or monitored.

There is an additional editorial note stating “chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately.”

CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.

In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of conditions that pose a real risk to the patient’s health and well-being. The practice must implement a care plan that addresses the patient’s conditions and a clinical staff member must spend 20 minutes during a calendar coordinating care and communicating with the patient. The practice must use a certified EHR. The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan. A copy of the care plan is provided to the patient, electronically or on paper. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services.

Informed consent is required before starting the service. The practice must inform the patient that they will provide this service and get written consent from the patient to do so and to share information with other providers. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.

CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office

It looks like a lot of work to me for $40.00. The practice may only report this service during the month in which the clinical staff has 20 minutes of non-face-to-face time with the patient. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

If you have your 2015 copy of the CPT book—and, again, I hope you do– you can read for yourself in more detail what the billing rules are. I am summarizing these but it is no substitute for reading them yourself. First, both CPT and CMS state that clinical staff should be doing the work. Also, a practice may not count any clinical staff time on a day when the physician or qualified healthcare professional (NP/PA) has an evaluation and management service with the patient. However, E/M services may be reported during the same calendar month the chronic care management is provided. There is a list of services in the CPT book that are bundled into chronic care management. These include care plan oversight and transitional care management, amongst other codes. The surgeon may not perform chronic care management during the postop period.

If your practice is already a patient centered medical home or you are already providing case management for a group of chronically ill patients, you are ready to begin performing chronic care management. However, if you are not already providing the services it is unlikely that you will be able to do these starting January 1. It requires an infrastructure within the practice to provide the services. Also, you will need to have an evaluation and management service with the patient to explain the service, sign the informed consent, and develop the care plan. This calls for gradually rolling out chronic care management services not immediately reporting them on all patients who will be eligible. Remember this is not a per member per month benefit– just because you provide the service one month does not mean you can provide the service the next month. The clinical staff must spend at least 20 minutes providing these coordination and care management services in order to report them. Most practices don’t have a template or form setup for this. Groups will need to think about how and where this information is being documented before rushing to bill for this service.

By Narath Carlisle, MD, MPH

Clues that your SCRIBE is in DISGUISE

Scribes in medical practices are in the news as a way for physicians to more effectively care for patients and use their EHRs. The scribe enters the exam room with the physician and does all of the data entry or typing while the physician takes the history, does and describes out loud the exam and develops the treatment plan with the patient. The scribe doesn’t interact directly with the patient at all, and probably isn’t the medical assistant who roomed the patient. The scribe writes, “Scribed by Betsy Nicoletti.” The physician reviews the scribed note, edits it and signs it.

 But, sometimes, medical practices don’t understand the concept of a scribe. Here are tell tale clues that the person who is “scribing” isn’t really a scribe.

  • Instead of saying, “Scribed by Betsy Nicoletti” the note says, “Dictated for Dr. Palmisano.” Huge warning sign!
  • Your scribe is disguised as a student: Medical student services are never billable services, and a medical practice can’t use the student documentation as a basis for submitting a claim to an insurance company. It usually isn’t the model for students. The student doesn’t sit and type while the clinician asks questions and examines the patient, as a scribe does. In case you need more information on this, page down to my most recent post. This relates to PA and NP students, as well.
  • Your scribe is disguised as an NP or PA or physician with an advanced degree: But, the practice has neglected to enroll the PA or NP with insurances because the medical professional is “only filling in for this week” or “really never works on his/her own.” This is an enrollment issue. Medicare and Medicaid enroll physicians, NPs and PAs, so get them enrolled and report the services appropriately. Contracts with commercial insurers vary. In some models, the PA/NP sees the patient first, does the bulk of the documentation and then the physician arrives and does a briefer visit. Report that service under the PA/NP provider number. “Dictating for Dr. Orthopedist” is not scribing as defined above and does not allow you to report the service under Dr. Orthopedist’s NPI.
  • Your scribe is disguised as an NP or PA and is doing a procedure that typically only a physician or NP or PA would do. Re-read the above example. Your PA/NP may perform procedures independently or incident to. If independently, report under the NP/PA provider number. If incident to, be sure the Medicare incident to rules are met.
  • Your scribe is disguised as you, in the room without you, asking questions or doing an exam, disguised as an independent practitioner: Scribes are typically medical assistants trained to work with a clinician as a scribe in the room. They don’t ask questions, do a physical exam or formulate a tentative plan. They don’t interact with the patient. A scribe is like a fly on the wall, recording what happens in the exam room.

If you are using scribes, that is a terrific way to unchain a physician from data entry. But, look at the list above and make sure your scribe is really a scribe. Don’t use the concept of scribing as a way to not enroll eligible professionals.

Have I got a Policy for you! Copy and pasting in an EHR.

The purpose of the medical record is to help the doctor and other doctors and healthcare professionals treat a patient.   Medicare and other third party payers can only be expected to pay for work performed at an E/M service on that date of service.  A payer doesn’t pay for work done at a previous visit, and copied into today’s note. With copying and pasting notes in EHRs, the rule is that you should not document it if you did not ask it, review it, examine it or consider it. If you copied from a previous note, read your new note and see if it contains any details that do not meet one of those criteria. If so, delete that element.

Let’s divide the History of the Present Illness (HPI) into two sections: a clinical summary and a section called, “since last seen.”

Clinical summary within the HPI: At times, it is useful for a physician/NPP to copy a clinical summary of the patient’s condition from a previous note.   When doing this, label it as copied and date the note from which it was copied.

Clinical summary from 1-4-14 “XXXXX”

Since last seen:  In this section, add the HPI elements or status of the patient’s condition since the last visit.

ROS:  Document the ROS as asked and reported by the patient today.  I don’t recommend copying from a previous note, even though the Documentation Guidelines allow it.  It doesn’t make sense to me and leads to inaccuracies. If the patient fills out a paper or electronic questionnaire, be sure to initial and date it.

Past medical, family and social history:  This can be imported from a previous note as long as it is reviewed with the patient.  Either update the history or note that no changes were required.  Only import the sections of the note that are needed for today’s visit.  I suggest refraining from importing family history routinely.  For 99214 only one of past medical, family, or social history is needed. For 99215, two of past medical, family and social history are needed.  If family history isn’t relevant to the visit, don’t add it to the record.  It contributes to the appearance of an overly cloned note.

Exam:  Exam is always new and should describe only exam elements documented at this visit.  Some clinicians find it useful to import a previous exam as a reminder of abnormal elements for this patient and state it is more accurate than “normal exam” because it relates to the patient being seen.  I personally do not recommend copying the exam from a previous note.  But if it is copied, it must be edited and reflect only exam elements performed at this date.

Data:  Many clinicians find it useful to carry forward in a progress note results of diagnostic tests.  It is easier than looking through the computer for tests results that may require multiple clicks and many minutes to find.  This is useful, clinically. Only new data either ordered or reviewed during the visit would be credited to determine the level of service.  Historical data re-reviewed could be credited, such as, “Comparing the EKG today with the EKG from 2012…”

Assessment and plan: A physician is paid for the conditions being managed at this visit, not for conditions managed by another physician or for conditions not addressed or reviewed at this visit.  The assessment should clearly note which problems were addressed today.

If the patient has problems not addressed at this visit, but listed in the A/P, label these as such. Insert a statement before the list, “other medical problems not addressed at this visit.”  Clinicians find it helpful to import this data into the note.  But, then, don’t use it to select a level of E/M service if the conditions were not addressed at this visit.

I suppose in a blog it is redundant to say this is my opinion?  This is my opinion, supported by reviewing OIG reports, the Documentation Guidelines, discussions with physicians, lawyers, coders and experience reading thousands of notes a year.  Obviously, obtain professional advice before adopting any policy.  CMS has not released a policy about this topic as of this date.