Getting paid: The date of service dilemma

Q: I am a primary care physician in a mid-sized medical group, and we are having difficulty determining when a modifier can be used and when an additional evaluation and management (E/M) code can be billed in addition to an Annual Wellness Visit (AWV). Clearly if a new problem is evaluated and addressed the service seems warranted.

The issue seems to be with patients that have medical problems that are stable. Is it appropriate to add a modifier and code if those problems are addressed in both the history of present illness and assessment, medications are continued, an appropriate physical exam is done and labs are ordered or reviewed?

a: Yes, it is appropriate to bill an AWV and an E/M code on the same date of service. You should append the 25 modifier (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.)
The AWV is basically a risk assessment and has specific criteria to document in order to bill, which can be found at Annual Wellness Visit. The AWV does not include services rendered to address a medical condition, regardless of whether or not it is stable.  
Make sure you document all of the elements of the E/M and AWV, so that each service is supported.
Q: Since some of our physicians round in the hospital, we would like to know what changes are being made to the Two-Midnight rule?

a: On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released updates to the Two-Midnight rule regarding when inpatient admissions are appropriate for payment under Medicare Part A. These changes continue CMS’s long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries.  
In recent years, CMS’s Recovery Audit Contractors (RAC) have identified high rates of error for hospital services that were billed as inpatient when they should have been billed as outpatient. Contractors also identified extended periods for outpatient stays, which don’t count toward the Skilled Nursing Facility (SNF) requirement of a three-day inpatient hospital stay.
Therefore, CMS created a Two-Midnight rule for hospital admissions, which states:

Inpatient admissions would generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation.
Medicare Part A payment was generally not appropriate for hospital stays expected to last less than two midnights. Cases involving a procedure identified on the inpatient-only list or that were identified as “rare and unusual exception” to the Two-Midnight benchmark by CMS were exceptions to this general rule and were deemed to be appropriate for Medicare Part A payment.

Medicare clarified that, “The Two-Midnight rule also specified that all treatment decisions for beneficiaries were based on the medical judgment of physicians and other qualified practitioners.  The Two-Midnight rule did not prevent the physician from providing any service at any hospital, regardless of the expected duration of the service.”

The changes that took effect January 1, 2016, were as follows:

For stays for which the physician expects the patient to need less than two midnights of hospital care (and the procedure is not on the inpatient-only list or otherwise listed as a national exception), an inpatient admission may be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician.  The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review.
CMS is reiterating the expectation that it would be unlikely for a beneficiary to require inpatient hospital admission for a minor surgical procedure or other treatment in the hospital that is expected to keep him or her in the hospital for a period of time that is only for a few hours and does not span at least overnight. CMS will monitor the number of these types of admissions and plans to prioritize these types of cases for medical review.

For hospital stays that are expected to be two midnights or longer, the policy hasn’t changed. If the admitting physician expects the patient to require hospital care that spans at least two midnights, the services are generally appropriate for Medicare Part A payment. This policy applies to inpatient hospital admissions where the patient is reasonably expected to stay at least two midnights, and where the medical record supports that expectation that the patient would stay at least two midnights.  
This includes stays in which the physician’s expectation is supported, but the length of the actual stay was less than two midnights due to unforeseen circumstances such as unexpected patient death, transfer, clinical improvement or departure against medical advice.

So what does all this mean for our physicians and providers? The lesson here is the importance of complete documentation by the admitting physician/provider. The physician/provider’s expectations of the length of stay must be clearly documented in the record.   
Q: We have been having problems getting paid by commercial insurers when we administer flu shots during a regular E/M visit even if we attach the -25 modifier to the vaccine and administration. They would pay the vaccine and the administration but not the E&M visit (i.e., 99214). Short of having patients come back on a different day just to get the flu shot, what should we do?

a: First, I would suggest that you look at the reason for denial on the carrier’s remittance advice. Each denial should have a denial code and description. This could give you some insight as to what the payer expects, and will also help you identify which carriers are not reimbursing for both codes when they are billed on the same claim.  
Normally, you shouldn’t need to append the -25 modifier to the E/M code. However, each insurance carrier can have different rules.  
Once you have determined which insurance carriers aren’t paying one or both codes when billed together, check each carrier’s website for policies regarding this billing scenario.  If there aren’t any clarifying policies on a payer’s website, I would suggest calling the carrier to ask for clarification.

Tips when you call:

Ask for someone who can help clarify a denial that you received.
If that person can’t answer your question, ask for his/her supervisor. If the supervisor can’t give you an answer, ask for his/her supervisor.  While this process takes a great deal of time, it could be well worth it. When you find someone who is knowledgeable and helpful, ask for his/her direct line.  
If an insurance representative refers you to their website for the information, get on your computer as you’re talking and request that he/she show you step-by-step where to find the information. It is vital that you have the information in writing for guidance and appeals.
Be nice! Let them know that your providers want to do the right thing but that you need the carrier’s help to understand how they want these visits billed.

Renee Dowling, is a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your coding and billing questions to: medec@advanstar.com.