Not Reflecting Medical Necessity; TCM/Home Visits; Split-Bill Encounters

Medical Necessity

Q: I was audited by a payer and their criticism of my medical decision-making documentation was that some notes had lists of diagnoses that did not reflect medical necessity. What do they mean by that?

A: In a perfect world they would tell you. But if they didn't, you have to look to the standard guidelines for this.

What the federal guidelines require is that diagnoses reported have a status of the problem and a plan. This could be as simple as, "HTN stable continue Metoprolol." As may have been the case with you, sometimes there are just lists of diagnoses with no indication of either status or plan - the problems are just listed or named.

When we don't see these same problems listed in the HPI (history of present illness), we wonder whether they are really actively managed that day - or whether they are more being mentioned in the A/P. Sometimes doctors use the A/P area as a running problem list, not always indicative of what was actually managed or assessed that day.

So give them what they want - state the problems to be addressed in the chief complaint, give a brief status of them in the HPI, and give us your assessment and plan in the A/P.

TCM Home Visits

Q: I did a transitional care management (TCM) that was a home visit. Can I charge for both?

A: A TCM code doesn't represent a singular service or visit, it is several things that occur in the 30 days following a patient's discharge from an inpatient stay. This includes the two-day contact, a visit within either of the specified periods, and the overall months' worth of oversight.

So when you ask if you can bill for both, it depends. If you mean can you use the home visit to count as the seven-day or 14-day visit included in the TCM code, then yes, but you wouldn't separately bill for the home visit. If you had another visit, in the office for example, within the seven day to 14-day range, and then did a home visit later in the month, between 15 days and 30 days post-discharge, then you can bill for the home visit in addition to the TCM code.

There is no exclusion for the use of home service codes in the TCM period, once you have done the required evaluation and management (E&M) visit in the 7-day or 14-day period. This is different for Chronic Care Management (CCM) services where there is an exclusion for home services in the same month that you are billing CCM.

Use of Modifier 25

Q: When Medicare audits the use of modifier 25 along with my Annual Wellness Visits, what exactly are they looking for?

A: They are looking to see if the evaluation and management visit billed along with the Annual Wellness Visit (AWV) was supported by documentation and medically necessary.

This begins with the chief complaint and history of present illness that needs to state clearly the purpose of the visit was both prevention and problem management, and that the rest of the note goes on to detail two distinct services.

We often see the E&M or problem portion of the note is missing some detail and there are frequently variances in the quality of the AWV portion. Remember, Medicare is looking for 10 or so specific items in this service.

So the use of modifier 25 to indicate two separate and complete services is dependent on the quality of documentation for each service.

Some providers have made an easy-to-fill-in template for combined services of this type. And if they do the work - they can have both codes. To be certain that you'll meet medical necessity criteria, you may want to select a patient with a combination visit, look at the last three visits before that one, and the next visit - to check for necessity and any cloning or cutting and pasting.

That is where we may find some medical necessity issues related to the E&M. If the patient had just been seen for those problems, they wouldn't need to have them assessed again at the time of the AWV. There are providers that just "mention" other medical problems to get the second code.

Split Bill Encounters

Q: Is it compliant to split bill encounters to insurance companies such as CPT 99213 on one encounter and labs and an office procedure billed out on a separate encounter all for the same date of service? 

A: Whether a particular billing practice or configuration of codes and claims is compliant is sometimes more a question of payer payment policy.

What you described as split billing, which is dividing elements of a single visit into two separate claims. It is acceptable in some circumstances, not in others. Usually we are talking about taking professional services performed and billed by a provider on a CMS 1500 form, and more technical or facility services performed by or supported by a facility or hospital outpatient setting. These are billed by the facility on a different claim form, a UB-04.

When an insurer recognizes the "split" between professional providers and the facility, two claims may be appropriate. This is the traditional split billing that Medicare in part created by virtue of Medicare Part A and Medicare Part B.

Most commercial payers don't want to see this. In your question, it sounded like you wanted the 99213 on one claim, and other services on another. You mentioned a lab and a procedure. If the lab work and procedure was performed by facility staff using facility resources - then you have a case for separation. But it almost sounded like you wanted two CMS-1500 forms.

Be sure that you are using the terms correctly. You can split between distinct entities when each provides a portion of a service, but you can't really sub-divide a professional claim into separate claims. 

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is an AAPC-certified instructor and has been active in physician training for more than 25 years.

This article originally appeared in the October 2015 issue of Physicians Practice