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Compliance Newsletter: Q3 2013

Compliance Newsletter: Q3 2013

Medicare Critical Care Pre-payment Audits

MedData and the house of Emergency Medicine are experiencing an increasing volume of Medicare critical care (pre-payment) audits. Our success in defending these critical care encounters is based on the “working definition” outlined by CMS, the use of the “Critical Care Descriptor Tool” we have shared with our clients and the thoroughness of the providers documentation of the critical care encounter.

Critical care is defined by CMS as the “direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”

“Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

“Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.”

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care services must be “medically necessary and reasonable”. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured, in accordance with the above definition and criteria is not payable and is not defendable in an audit.

Critical care services encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.” Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. (i.e., the patient shall be critically ill or injured at the time of the physician’s visit). Not “possibly” critical (i.e. Roll over with no critical injuries).

Locum Tenens Billing Arrangement

MedData urges clients to notify us when locum tenens services are planned, in order to ensure our clients compliantly utilize locums physicians based on CMS guidelines and that those services are billed compliantly.

Locums have been used forever to substitute when the regular physicians are absent for any reason—an illness, a pregnancy or a vacation. The regular physician can bill and, when assignment is accepted, receive payment for the substitute physician’s services as though the regular physician performed them.

The way a physician can be paid for a substitute physician’s services is through the locum tenens billing arrangement. In this arrangement, the substitute physician generally has no practice of his or her own. The regular physician (the provider that is normally scheduled to see the patient) generally pays the substitute physician a fixed amount Per Diem. The substitute physician would have the status of an independent contractor rather than an employee.

A regular physician (which may include physician specialists) may bill for the services of a locum tenens physicians if:

  • The regular physician is unavailable to provide the visit services;
  • The Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician;
  • The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis;
  • The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days; and
  • The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code.

Non-physician providers (PA’s/NP’s) cannot work in the capacity of a physician locum and are not recognized by Medicare under the physician locum billing guidelines.

The same rules apply to a locums substituting for a regular physician in a group. The same 60 maximum requirement exists.

Medicare requires the group keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s UPIN, and make this record available to the carrier upon request.

ICD-10 Provider Documentation Training

MedData will be implementing ICD-10 clinical provider education training during the first quarter of 2014! The degree of success a practice will have transitioning to the new ICD-10 code set will largely be determined by how well they prepare themselves prior to October 1, 2014. Preparation can be a fairly simple process if key components are addressed. The problem many groups will have is procrastination or insufficient preparation. The key components that should be considered as groups prepare for a successful transition is documentation evaluations, identify documentation deficiencies in laterality (right, left or bilateral), episode of care (initial, subsequent or sequela), and anatomical specificity (wrist versus distal radius), and providing training on required specificity.

Training will consist of the following:

  • Evaluate the current documentation in preparation for ICD-10
  • Identify deviancies and education needed to improve documentation
  • Identifying Documentation Challenges
  • How to avoid denied claims and reduce the risk of interruption in revenue
  • Learn how to document for ICD-10 based on specificity of (laterality, episode of care, and anatomical location)
  • Learn the ICD-10 structure code set guidelines and requirements
  • Documentation Exercises and Documentation Case Studies
  • Review case examples
  • Provide regular Documentation Deficiency Feedback to identify outliers and areas of documentation risk

A real challenge for coders will be documentation insufficient to support the specificity required for the new ICD-10 code sets. The coders will be fully prepared for the transition. If the clinical documentation does not meet the specificity requirements, then accurate coding and proper payment may not be possible. A behavioral change in documentation habits for many providers and clinical personnel will be necessary to address the specificity requirements of ICD-10-CM.

For example, if a patient presents to the emergency room a with a sore throat and you do a simple exam, palpate the throat, have the nursing staff perform a strep swab, which turns out positive, and diagnose the patient with strep throat, your regular documentation will suffice. This is because there are not many more specific details needed for this exact diagnosis.

If the patient visit is more complex, your documentation will also have to be much more complex, containing details that the medical coders will need in order to assign the correct diagnosis code per ICD-10. For example, your patient is a middle- aged woman who was cooking in her kitchen, when a pot fell off the wall and hit her in the head, causing a concussion and intractable headaches. Because of the many variables in this scenario, your documentation must be as specific as possible, keeping in mind the many different aspects that you will need in order for the medical coders to assign the correct ICD-10 codes in the final impression.

More Clinical Documentation – Patient Charting Focused Skill Set

There are many daily chores to being a good practitioner. Patient care, nursing staff issues, medical decision making, patient paper work and referrals, constant prescription refills requests; the list goes on and on. Patient charting is one of those crucial daily tasks, which cannot be overlooked, and which you must complete to the best of your ability, all the while seeing other patients, and dealing with all of your other responsibilities in the clinical setting. Come October 1, 2014, this specific responsibility will become even more imperative.

2013 PQRS (GPRO) Group Physician Reporting Option (Provider +100 or more)

For the 2013 PQRS program year, a “group practice” is defined as a single Tax Identification Number (TIN) with 2 or more individual eligible professionals (as identified by Individual National Provider Identifier [NPI]) who have reassigned their billing rights to the TIN.

Providers who are currently participating in PQRS (claim base) reporting and all MedData clients do report PQRS, and have less than (100 providers) under a single TIN# do not have to re- register.

Groups with 100+providers *(NPI’s Per TIN) in 2013 must self-nominate/register to participate in PQRS GPRO by Oct. 15, 2013.

The 2015 PQRS payment adjustment will be based on data collected from the 2013 PQRS program year.

If your group is > 100 providers contact your Client Services Director and MedData will walk you through the process.

Medical Students

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

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

  • Students may perform and document ROS, past medical, social and family history. The teaching physician has to review and agree just as with nursing documentation of the same.
  • Attending must document that they personally performed HPI, PE and MDM and the results of these components. This may be in the form of a tether or a unique note by the attending.
  • If the medical Student documents the HPI, PE or MDM without a clear attending note (documented by the ED provider), the chart will need to be placed on the “Needs Action” report and an addendum needs to be requested from the attending physician with their documentation of the HPI, PE and/or MDM. If the main components of the E/M were performed and/or documented by the student, the chart is non-billable for ALL PAYERS.

The teaching physician refer to the Medical Students documentation of HPI, physical examination findings or medical decision making in his or her personal note is of no value from a billing standpoint.


Procedures performed by students “cannot be billed” unless it is clearly documented that the teaching physician performed that procedure. Procedures performed by a medical student are not billable for any payer.

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