Primary-Care Exception and PAs; Preventive Exam and E&M

Primary-Care Exception and Physician Assistants

Q: If a teaching physician is using the primary-care exception (PCE) and he is supervising fewer than four residents, can a physician assistant (PA) be included in the mix of four that the teaching physician is supervising? The teaching physician is using the PCE that allows supervision of a maximum of four residents.

A: I do not think a PA can be included in the mix due to the condition that the attending: "Have no other responsibilities, including the supervision of other personnel, at the time services are furnished by residents." (See http://go.cms.gov/1d2M9Co).

On one level the PA doesn't factor into the exception equation because Medicare doesn't have anything to do with their reimbursement. On the other hand, the "other responsibilities" language above translates pretty directly into a "no" answer to your question. However, as a practical matter I suspect this is violated regularly in the name of efficiency, revenue, and volume.

Preventive Exam and E&M

Q: What do I need to do to better document the Medicare preventive exams when combined with an E&M? I have been told that I am missing things. How do preventive exams and regular annual exams differ?

A: Medicare calls these exams annual wellness visits (AWVs), and they require you to address some very specific items that differ from a typical or historical preventive service.

First off, you called it a "Medicare preventive exam." Try and be more precise in the terminology. The AWV doesn't actually include a physical exam, and if you do one for these visits you are going above and beyond somewhat. In that case, Medicare would be happier if you called it an AWV and management of "X."

If you are providing both the AWV and an E&M service, as more and more providers are doing of late, document the history of present illness associated with the problems assessed first. Then move on with your normal review of systems; past medical, family, and social history; and exam associated with both aspects of the visit. AWVs also require some assessment of cognitive impairment and a couple of other items that are often not stated clearly in the note.

The most commonly overlooked elements are:

• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.

• Detection of any cognitive impairment that the individual may have.

• Review of an individual's potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose, and recognized by national professional medical organizations.

• Review of the individual's functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose, and recognized by national professional medical organizations.

• Establishment of a written screening schedule for the individual, such as a checklist for the next five to 10 years, as appropriate, based on recommendations of the U.S. Preventive Services Task Force and Advisory Committee of Immunizations Practices, the individual's health status, screening history, and age-appropriate preventive services covered by Medicare.

Although you may have actually addressed these elements in your comprehensive exam and note, use the language CMS uses (i.e., no cognitive impairment detected). There may also be a list of other providers elsewhere in the chart. If so, just reference it.

Ask your administrator to get you a copy of the AWV outline from Medicare.

Health Risk Assessment and Annual Wellness Visit

Q:  If a patient does not fill out the health risk assessment (HRA) portion of Medicare's AWV regarding activities of daily living (ADL) and instrumental activities of daily living (IADL), but the patient does perform the up and go test for the nurse, can we use that test for the HRA requirement of ADL and IADL, as well as using it for the review of the beneficiary's functional ability and level of safety (ability to successfully perform activities of daily living)?

A: There is no more specific guidance on these elements other than what it says in the Medicare transmittals. They don't talk about double use, versions of things, or partial things. It is really up to you whether you think one of these services has all its pieces. The elements of the HRAs don't specify required elements for the HRA, just suggestions. It's kind of up to you what you think is defensible and thorough. It would be nice if all these things were quantified but such guidance is not always available.

Fracture-Code Time Frames

Q: I'm an orthopedic surgeon and I was recently told that I shouldn't be using closed fracture treatment codes two weeks or three weeks after the initial injury. Is this the case?

A: The CPT book states that "a physician that provides the definitive fracture care following a treatment to stabilize or protect may bill the fracture care codes" but it gives no time frame for this lapse between initial treatment and "definitive" treatment. An example of when such a time lapse might occur between initial and definitive treatment would be a Friday night ER visit with a cast and follow-up Monday or Tuesday of the next week with a cast replacement.

 I can see a good use of the fracture care code within a reasonable proximity to the injury - perhaps up to seven or 10 days - but it would not appear as reasonable beyond that time frame. The real indicator as to whether you should use the treatment code is whether the patient clinically requires the treatment - that will be the ultimate defense.

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at billdacey@msn.com. He will help clear up the confusion, and you may even see your question featured in the journal.

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.

This article originally appeared in the January 2014 issue of Physicians Practice.