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Compliance Newsletter: Q3 2012

Compliance Newsletter: Q3 2012

CMS Clarifies Three-Day Payment Rule

(Bundling of Payments for Services Provided to Outpatients Who Later Are Admitted as Inpatients: 3-Day Payment Window and the Impacts on Wholly Owned or Wholly Operated Physician Offices) are not applicable to physician and MLP professional services furnished in the hospital outpatient department, including the emergency department.

In the calendar year (CY) 2012 Medicare Physician Fee Schedule (MPFS) final rule, published November 28, 2011, CMS finalized the 3-day payment window policy’s application to physician fee schedule services consistent with section 102 of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (PACMBPRA) (Pub. L. 111-192).

Frequently Asked Questions CR 7502

Q.30. Should the modifier PD be used to identify outpatient physician or practitioner services, subject to the payment window, that are performed in the hospital?

A.30. No, the CMS modifier PD should not be used for outpatient services subject to the 3-day (or 1-day) payment window that are furnished in the hospital. For example, the modifier PD should not be appended to physician and practitioner professional services furnished in the hospital outpatient department, including the emergency department, patients receiving observation services, or other outpatient services furnished in a provider-based department of the hospital. The CMS modifier PD should only be used for diagnostic and related non- diagnostic outpatient services paid under the Medicare physician fee schedule that are furnished in a wholly owned or wholly operated physician practice (or other Part B entity) of the hospital. The modifier PD should not be appended to a claim where the payment window policy applies but the service was provided in a hospital. In other words, the modifier PD should be used to identify related outpatient services subject to the payment window furnished in the physician’s office and not by the physician at the hospital.

Please reference the CMS for more FAQ’s responses on this topic.

Moderate Conscious Sedation

Moderate (Conscious) Sedation [MCS], is a drug-induced depression of consciousness. The patient maintains the ability to respond purposely to verbal direction or verbal direction either alone or accompanied by light tactile stimulation. Interventions are not required to maintain the patient’s airway.

According to CPT, Moderate (Conscious) Sedation includes: Assessment of the patient, establishment of IV access, administration of agent(s), maintenance of sedation, monitoring of oxygen saturation, heart rate, and blood pressure, and recovery.

Moderate conscious sedation includes performance and documentation of:

  1. Pre- and post-sedation evaluations of the patient
  2. Administration and name of the sedation and/or analgesic agent(s), and
  3. Monitoring of cardio-respiratory function (i.e. pulse oximetry, cardio-respiratory monitor, and blood pressure)
  4. Start and stop times—this is from the time the drug is administered until the procedure is completed. *Should be documented separately from the trained observer monitoring time and should be representative of the physician continuous bedside time with the patient.
  5. Who performed the procedure associated with the sedation—the same (ED) physician or was supervision of sedation done in support of another provider performing the procedure (i.e. an orthopedist reducing a fracture).

The use of these codes requires the presence of an independent trained observer to assist the provider in monitoring the patient’s level of consciousness and physiological status. This is usually evident in the sedation flow sheet.

A minimum of 16 minutes* of inter-service time must be provided and documented.

Medical Students

Any contribution and participation of a medical student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements, other than (ROS, Past, Family & Social History) which are taken as part of an E/M service and are not separately billable.

Medical students “do not exist” for HPI, PE and MDM (cannot document these main components of the E/M, must be documented by the ED provider).

Teaching setting: A medical student may document services in the medical record; however, the teaching physician may only refer to the medical students’ documentation of an E/M service that is related to the ROS and/or PFSH.

The teaching physician must document that he/she personally performed HPI, PE and MDM. This may be in the form of a tether or a unique note by the attending.

The teaching physician may not refer to the Medical Students documentation of physical examination findings or medical decision making in his or her personal note. If the Medical Student documents E/M services, the teaching physician must verify and re-document the history of present illness and perform and re-document the physical examination and medical decision making activities of the service.

The medical student should identify themselves in the ED record by either indicating “medical student” or the use of the initials (MS) after their signature (I.e., Signature: John Doe, medical student).

Procedures: The teaching physician should perform all procedures and must be physically present for the entire procedure and document his/her presence indicating personal supervision of the service including authentication of the entry.

Medical Scribes

Scribes are individuals trained in medical documentation who assist a physician throughout his or her shift. They serve as a personal assistant to the doctor to help make them more efficient and productive. The primary function of a scribe is the creation and maintenance of the patient’s medical record, which is done under the supervision of the attending physician. The scribe will document the patient’s story, the physician’s interaction with the patient, the procedures performed, the results of laboratory studies, and other pertinent information.

The physician is providing the service while the scribe is recording only information cited by the physician.

Who Can Act as a Scribe?

Since a scribe is only recording the words and descriptions of the service provided by the physician, consequently, anyone trained to be a scribe can act as a scribe. NPs and PAs cannot scribe and provide care on the same patient.

Attestation for Scribing:

“Written by Tom Jones, acting as scribe for Dr. XYZ.” (OR) “Tom Jones, ED scribe”


The physician must also sign note/ T sheet, etc.

CMS (ICD-10) Update

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) August 27, 2012.

The rule, which will be published in the Federal Register Sept. 5, ends months of speculation spawned when public comment was solicited by CMS in April. The rule, which also sets dates for health plan and provider identifiers, emphasizes providers and payers must adopt the code set by the 2014 date, which is a one-year delay from the previous implementation date.

One of the identified benefits for the United States’ transition from ICD-9 to ICD-10 is the increased level of specificity offered by the ICD-10 code format. This specificity will benefit patients and doctors (by giving more detailed diagnosis and treatment information), payers (by more accurately defining services) and international organizations that monitor worldwide disease.

Documentation will become critical

One of the largest problems following the October 1, 2013 implementation date for ICD-10 will be documentation insufficient to support the specificity required for the new ICD-10 code sets. Our objective is to provide ongoing updates and documentation training to ensure ICD-10 readiness amongst our providers and coding staff. If the office is fully prepared for ICD-10, but clinical documentation has not improved, accurate coding and proper payment will not be possible. We believe a behavioral change in documentation habits for most providers will be necessary—and now is the time to start preparing.

A clinical documentation evaluation will:

  • Validate sufficient ICD-10 documentation
  • Identify ICD-10 clinical documentation deficiencies.
  • Identify ICD-10 training specific to your needs.
  • Avoid an increase in denied or un-billable claims.
  • Prevent an interruption in revenue

(PQRS) Maintenance of Certification (MOC) Program Incentive

Continuing in 2012, physicians will have the opportunity to earn the Physician Quality Reporting System incentive and an additional incentive of 0.5% by working with Maintenance of Certification entity and by completing the following:

Satisfactorily submitting data, without regard to method, on quality measures under Physician Quality Reporting, for a 12-month reporting period either as an individual physician or as a member of a selected group practice.

More frequently than is required to qualify for or maintain board certification:

  • Participate in a Maintenance of Certification Program
  • Successfully complete a qualified Maintenance of Certification Program practice assessment.

The 2012 participation period has ended; ED providers must register as a MOC participating entity during the period of January thru March 2013.

Past, Family & Social History

Required for (99284-99285) and Observation codes (CMS rules)

  • No PFSHx is required for 99281-99283.
  • One (1) area of PFSHx is required for 99284.
  • Two (2) areas of PFSHx are required for 99285.
  • All three (3) areas of PFSHx are required for Observation codes.

PFSH information can be obtained by the nursing staff but the ED provider must review the nursing documentation of these elements and “confirm” findings or document any areas of disagreement. The ED provider must document or can utilize a macro statement indicating that he/she “reviewed and agree” with the nursing PFSHx and/or ROS.

Past History: may be summarized and may include major illness, surgeries, current medications, allergies, immunizations. It is not the same as a review of systems, which is considered a separate area of history documentation.

Social History: may include alcohol/drug abuse, smoking history, employment, marital status, living arrangements (children living with parents, disabled person in nursing home, etc.), education, etc.

Family History: may be focused on family diseases or conditions related to chief complaint, history of present illness or review of systems and/or hereditary disease that may put the patient at risk. This includes health status or cause of death of parents, siblings, and children.

Pediatric History: for pediatric patients, past history may include: normal vs. abnormal delivery status, immunizations, illness or injury, etc. Pediatric social history could include living with parents, school or daycare attendance, exposure to secondhand smoke, etc. Documentation of negative or normal findings may be the only PFSH (or ROS) available for an otherwise healthy child.

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