Coding: Preventive services; ICD-10 readiness; new ABN form

Prevention Planning

Q: I have heard that CMS is planning to pay for the larger preventive service codes in 2011. I know that they pay for some of them now … but not for the annual preventive visit outside the "Welcome to Medicare" visit. Is there any truth to this?

A: Not only is there truth to it - this is a long overdue improvement in Medicare coverage that will yield some significant revenue to primary-care providers. What follows comes to us through the Patient Protection and Affordable Care Act (ACA) which makes prevention much more accessible. The AARP has a fact sheet on this as well for greater detail.

Beginning in January 2011, we have two new HCPCS Level II codes: G0438 and G0439. G0438 is an initial visit for annual wellness which includes a personalized prevention plan of service. G0439 is a subsequent (used in subsequent years) annual wellness visit (AWV) which also includes a personalized prevention plan of service. These codes will be paid using the same relative value units (RVUs) as 99204 (office/outpatient visit, new, $155.23) for the initial AWV and 99214 (office/outpatient visit, est., $99.93) for subsequent AWVs.

These codes can be billed as incident-to, according to CMS. It is unclear exactly what requirements or performance standards the codes entail. It seems that CMS is requiring that all components of the codes be performed whether or not a given patient was at risk for specific conditions such as obesity, depression, or falls.

The personalized prevention component which the Final Rule refers to as "voluntary advance care planning," is something that a patient may elect to include in their visit. This element requires that providers address the patient's ability to prepare an "advance directive" and the willingness of the provider to abide by it. This is where all that "death panel" talk came from. Far from it, it allows for some intelligent conversation about practical end of life issues. This is already part of the Welcome to Medicare visit.

ICD-10 Transitioning

Q: It looks like ICD-10 is coming for certain - we've been kind of waiting since it was postponed so many times before. Is it really coming in 2013?

A: It's coming- and the deadline for ICD-10 implementation is October 2013. The Final Rule for adopting ICD-10 CM and ICD-10 PCS states clearly that the new systems have effective dates that will not be extended. So, 2013 it is. If you are still wondering if it coming, you are already behind the curve in preparing for it. This is much more than a software change or another annual coding update, it is a whole new system impacting the coding, billing, and payment of all your medical claims. Only self-pay patients that just receive statements without codes would likely be unaffected. It will involve your billing system, your EMR, your charge ticket, and impact almost all your staff. Your best bet is to follow a transition timeline to help you fully prepare. If you don't get proactive about this - there will probably be some loss of revenue in the transition. Both Ingenix and the AAPC have detailed benchmark trackers to help you mark your progress.

'History' Lesson

Q: My doctor and I disagree about which words signify which element in the History of Present Illness (HPI). How do we know how a Medicare auditor will interpret the things we say?

A: You don't know. That's probably one of the larger issues with the federal guidelines. Despite years of commentaries and interpretations, it all comes down to how a given reviewer reads a certain note on any particular day. It is highly subjective. That's why physicians need to make a point to include the most basic of details: how long, how bad, what made it happen, what makes it worse.

It's not that these aren't covered in most encounters; it's that they aren't documented.
The worst part about this, and the most obvious indicator of the subjective element of the HPI, comes from the online guidance at CMS. The very rules are seemingly askew:

"There are two types of HPIs: Brief, which includes documentation of one to three HPI elements. In the following example, three HPI elements - location, severity, and duration - are documented:

"CC: A patient seen in the office complains of left ear pain.

"Brief HPI: Patient complains of dull ache in left ear over the past 24 hours." (Italics supplied by Physicians Practice.)

If you look at the definition of the elements themselves;

"HPI elements are:

"Location. For example, pain in left leg;
"Quality. For example, aching, burning, radiating;
"Severity. For example, 10 on a scale of 1 to 10;
"Duration. For example, it started three days ago; …"

There is no question about location and duration - left ear and 24 hours. But you'll see that by their own definition the word dull might fit better under quality - yet they have recognized it as severity. So, subjective opinion right from the manual. You'd better list five not four for expanded HPIs - leaving some room for interpretation.

ABN Advice

Q: I know there was a new ABN form that we needed to start using sometime last year. We're a bit slow on some of these regulations. But lately I heard that if we aren't giving cost estimates of noncovered services and using modifiers that we have to "eat" the claim. Is this true?

A: Yes, there was a new form that became effective in March of 2009. The Advance Beneficiary Notice (ABN) became the Advance Beneficiary Notice of Noncoverage -but the initials are the same.

As far as "eating" the billed amount for ABN related services, it is true that if you either don't have an ABN on file, or it is improperly executed, you can't collect from Medicare or the patient.

A properly filled out ABN can shift financial liability for a noncovered service from the provider to the beneficiary - a defective ABN is ineffective to shift liability.

The cost estimate is a new mandatory item on the form. The notifier (provider) must make a good faith effort to insert a reasonable estimate for all of the uncovered items listed:

• In general the estimate should be within $100 or 25 percent of the actual costs, whichever is greater.
• Providers can insert in the noncovered services blank on the ABN a preprinted list of items or services with cost estimates alongside each item or service.
• If there is a possibility of additional tests or procedures whose costs cannot be estimated at the time of ABN delivery, enter initial cost estimate and indicate the possibility of further testing or procedures.
• If for some reason the notifier is unable to provide a good faith estimate, the notifier may indicate that no cost estimate is available.
• CMS expects that this will not be a frequent practice.

As far as modifiers go, there have always been modifiers associated with ABNs. The ones you need to know are:

• GA - Waiver of Liability on file. Use to indicate that an ABN was given (CMS 1500 form)
• GX - Use to indicate that an ABN was given for (UB – 04) [This is for facilities only]
• GY - Used when the item or service is statutorily excluded
• GZ -Used to indicate that an ABN was not signed

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.