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[Music] welcome to the code cast podcast real-world insights for your daily medical coding and billing processes and now here's your host Terry Fletcher hello everyone and welcome to the code cast podcast my name is Terri Fletcher happy to have everybody today hope you are doing well with your holiday shopping and getting into the last part of December and 2018 I don't know about you but I'm ready for 2019 2018 has been we call it the good the bad the ugly the challenging and I know we say that every year but definitely have some challenges this year but all you know a lot of good things happen but I'm ready to move on into the next chapter into 2019 and I hope everybody else is as well so in last week's episode I talked about not just pay refunds but also about mid-level providers NPP's and on physician practitioners nurse practitioners pas and everything that happens with that when it comes to an NP P performing services under a physician incident - or even performing independent services so I wanted to expand on that a bit this week and talk about supervision guidelines but I'm gonna back it up a little bit and just clarify some of the comments I made last week only because I received a flood of emails and just some things that you know and that people were like oh okay can I do this can I do that and I'd also wanted to comment for you out there just let me give you an understanding of what the the code cast podcast is and hopefully you'll appreciate what I'm trying to do here because I've been on the air now for over a year several different entities have picked up the program so now we're on iTunes and Spotify and YouTube and stitcher radio and tune in and you name it we're out there and Sirius XM radio is looking to pick us up as well as one of their program sites and so it's creating a lot of buzz and I appreciate that especially you know being considered an authoritative reference on on some of the topics but one of the things that I just wanted to make sure you understood and really can embrace for me I'm an independent consultant and that's what I do I am an educator within my coding and billing and reimbursement knowledge I've been in the business for over 30 years I'm a certified coder times 14 so I have four certifications 14 certifications in coding and then also I am an auditor not only do I audit on the private sector but also for Medicare and I do a lot of other things as well if you look at my website at Terri Fletcher net I'm sure you'll see I design waiting rooms for medical practices we we do all kinds of compliance manual creations we go out and do on-site training not just speaking at conferences and seminars and webinars and all that but the reason I wanted to bring this up is that the the podcast to me was a way for you to get information that you didn't have to pay for as long as as soon as they don't make podcast and podcasting a fee for service but not to the point where you're being trained where I want to give you insight to the point where if you want to expand this knowledge in an actual formal training session then I want to invite you to go to my website and sign up for a webinar that yes you would have to pay for but that comes with materials and links and information that you now can take back to your practice and utilize it as a training tool for yourself so this is for your your insight yes for your learning but more as oh I didn't know I could do that or oh you know now I I see where she's going with that or even something where you're like okay well I was wondering about that and now you're confident in your knowledge on something or something that maybe I gave you some insight that you were not aware of before but the formal training and formal coding questions and all that those are things that you do have to pay for and I just wanted to bring that to your attention only because I've had a flood of email which I love everybody loved you know my almost 30,000 listeners and I absolutely I'm so happy that we've have that kind of reach right now but when you submit a question or you give feedback on the podcast I just want to let you know how it works is that I'm happy to respond to a question but anything more than that I would ask you to go to my website and join something called the on-demand coding corner which is my unlimited question and answer service it's a yearly fee it's a membership and then you also get a yearly newsletter then you could sign up for that under contact us contact us on my website and then that comes actually out every quarter and then you can also get a discount on webinars and seminars and things like that so you know we keep us on the air and because I am an independent consultant that's how we generate our revenue and so the code cast is kind of like a pert something that I'm hoping you're enjoying listening to you find my sense of humor to bees along the line of yours and and it's just something that you can really just say okay give you some mindful and thoughtful thought-provoking things in the healthcare field hopefully some breaking news that you weren't aware of but I'm trying not to do it in instruction format that is more for webinars webcasts you know seminars conferences things like that live seminars this is more just for your insight so I just want to bring that to your attention because I don't want you to you know contact me and think okay now I can be trained through an email and all through the code cast I want you to use this code cast if if you don't mind me kind of giving you some direction here as something that you have in your back pocket going you know it let me let me just see if there's a topic on the the sick this is our 60th episode so on the 16th episodes that Terry's given us that really speaks to me things I need to know and then when you listen to the episode you're thinking okay so I need to expand on that where's the webinar that I can purchase and listen into and get the materials that follow that information otherwise you you really need to be on your own to look up some of the references I give you so hopefully you appreciate that and understand what we're going with that and again we just are really happy to have you listen in and and be on board with what we're doing here so we definitely wanted to just just kind of clarify some things there okay so let's take a look at this week but first the code cast podcast is brought to you today by movado watch company one of the world's leading watchmakers Movado modern ahead of its time Movado calm and simple health radio discussing topics related to your health and well-being simple health radio calm okay so in revisiting last week when it just comes to mid-level providers and some of the things that that go along with utilizing that physician extenders is what they're called formerly we have to really understand that different states are going to have different opinions and interpretations and what we call LCDs which are local coverage determinations on how to utilize those providers they're not physicians but they're utilized in a physician practice as a physician many times and so not only is there a federal guideline and you can find the the Medicare benefit policy manual guideline in chapter 15 section 60 and it gives all kinds of things within bold text but I've noticed that there's still some interpretive issues that may change how you utilize your mid levels and again I'm seeing some people interpret things where they're so ultra conservative and going to the actual verbatim that they're not looking at the spirit of the rules and what you can support and you know me if you've ever taken a class of mine or you know heard me speak anywhere I'm not going to tell you to do anything that on appeal or if it's questioned that you can't support I want to be especially being a Medicare honor I want to make sure that you are not only above board that you're not hanging on the edge of the cliff ready to fall over I want you to be able to you know be just saying yeah you know I'm an open book take a look at what we're doing here so a couple of things that I just wanted to bring to your attention there's a couple of opinions out there I should say several that may be different than my opinion and that's okay you know everybody has their own opinion my interpretation though of the rules is just a little bit different when it comes to your mid levels so you've got a patient that's a new patient visit and they are being seen incident to meaning the physician is in clinic the doctors started or initiated care and now the mid-level provider is now carrying out that treatment plan okay so question came up and said can a mid-level provider npp can they change or a dose of medication can they order an x-ray or anything like that and I saw that somebody had posted on one of the coding websites and they said that they they can create their own plan of treatment change the dose of medication and order an x-ray and so forth but at the moment that NP makes an independent treatment decision it's not under the physicians incident - it's under there's well that's half right you know your your mid-level providers the reason that they have the education that they do is because they can make independent decisions based on the patient's presentation and so and as long as it follows the physicians overall direction and control there's not going to be an issue when it comes to are you following the incident - so what I am understanding from the Medicare manual and what my interpretation is is that let's say that you had a patient that came in and they were a hypertension patient and your physician had put them on a certain medication but that medication wasn't working but they still had hypertension diagnosis they still needed medication for that and then NP said well let's try this medication they may be altering a little bit the basically the the treatment plan but they're not changing it it's not a new problem and it really is clear in the Medicare manual that says that it would have to be a new problem for it to be an issue and there is no new problem and so that's where you just want to not over analyze some of the conservative approach to that so if the patient's saying oh by the way I have this going on and now the NP basically says oh okay well we're going to do this to treat that problem then absolutely that is a plan of care change that is not something that the physician diagnosed and so that would be part of that physician issue and also in that policy manual it says there may be changes in the course of treatment over time but a physician is required to make those changes well changes means that you're changing what's going on this is not a change this is a modification of a medicine that was already prescribed for a condition so I I'm interpreting it just a little bit probably less conservative but I believe that it will stand up to muster especially since I'm auditing these records so it's it's interesting just when you see this from a state level as well so Indus Indiana State Medical Association came up with something and thank you too Pam Shulman and Florida medical clinic she show this he says the physician ordered a drug at a certain dosage for a patient the NPP sees a patient and a follow-up visit and determines the drug is not working the drug and dosage or change can the service be billed as an incident to service okay so in Indiana they're saying that because the NPP is now determining the plan of care that's not an incident to requirement but I took this to Pennsylvania in California and Texas in Washington State and they said oh no the patient was still under this under a plan of care for the same conditions same problem just a change in medication that's not a change in treatment plan and so look to your state see what your state says on this because in Indiana that's what they believe but in five other states I queried they said no it's still the treatment plan for this patient to try and be treated and serviced under medication regardless what the medication is it was just a modification so again I just wanted to make sure you were clear on that so that you're not thinking that you're reading the rule one way hearing something else and thinking okay what do I do here and and that can happen so you have to ask that question to your Matt carrier make sure that know sometimes they don't get back to you 90 days but if you're at all concerned then you want to really you know get that information from that Matt carrier and see what they say about it because if you're not comfortable you know looking at the the rules from an interpretive standpoint and you just want them to be black-and-white which I don't think any coding rules are - for the most part I think otherwise your doctors wouldn't need us it would be black and white and they just do this I think that you need to do a little bit more due diligence so that's what I wanted to bring to you just to follow up on what we were talking about last week but then I wanted to move into a topic called supervision guidelines now I know what we're talking about here sounds like supervision guidelines but it's really incident to guidelines meaning just about established patient visits and so when we talk about supervision we're talking about for diagnostic tests performed in a non hospital setting so that would mean physician's office or independent diagnostic testing facility and so you know where does your doctor have to be when let's say a stress test is being performed and where does your mid-level have to be or what is what gets built under them when your patient is having a test done and the doctor doesn't happen to be there so this comes right from the Medicare benefit policy man your will stand still in chapter 15 but in section 80 there's three levels of supervision so there's general supervision and that means the procedure is furnished under the physicians overall direction and control but the physicians presence is not required during the performance of the procedure so under general supervision the training of the non physician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies that's continued to be this responsibility the physician so what would follow under general so let's just take a look at a couple things so labs EKGs echos halters events ultrasounds things like that things that you can tell are not really invasive now you have something called direct supervision and this is where sometimes there's a little bit of a confusion saying well direct supervision incident to remember incident to for mid-levels is just about office visits direct supervision but there's a direct supervision guideline of where the doctor has to be in clinic but direct supervision requirements under Medicare supervision requirements is about testing so once you have that understanding that there is a difference there then you'll be fine but direct supervision is in the office setting that means a physician must be present in the office suite and immediately available to furnish the assistance and direction throughout the performance of the procedure so it doesn't mean that the physician must be present in the room and the procedure is performed it just means that they have to be and we call it within yelling distance and what would be examples of direct supervision well we would be looking at stress tests so treadmills or pharmacological inductance stresses some forms of nuclear medicine PET scans so anything that is invasive for before a physician that has to deal with that so personal supervision that's the next one means a physician must be in attendance in the room during the performance of the procedure that and so you know heart Cath's tes when they're actually in the room performing the service and just look at your Medicare fee schedule database if it has an indicator on it which is one for general two for direct or three for personal you know what it is now this does not apply to tests performed in hospital settings that's different and you want to make sure that you're understanding your billing more interpretive codes instead of Global Services and that's really the key here is that these are global services so you're billing the one code instead of splitting it up technical and professional and supervision by a non-physician practitioners and nurses or PA that doesn't qualify as physician supervision that's where the you can see that there's a definite difference between this and when we were talking about the office visit incident to supervision because that the mid-level or the non physician practitioner does qualify as a physician as long as there's a physician clinic so it's a little bit different but if it's this performance of a specific test is within that practitioner scope of practice under your state statute immersed at stuns States Trump the federal government which you find kind of interesting but when I say that did I just say states Trump the federal okay sorry I made a funny didn't mean to make that but what I'm talking about here is that states will basically say okay well this is what we will allow it doesn't matter what the the federal government says this is what we're saying and you have to go by that because there's different State Board of Nursing based on the patient population and so again when the when the performance of a specific test is within that practitioners scope of practice under the state statue then they would build this using their own Medicare provider number and also if they're credentialed with a certain commercial plan so for example if a nurse practitioner administers a stress test as permitted under your state statute then they then a claim can be submitted to Medicare for the stress test under the mid-level providers pin number even though there was not a physician present in the office suite so you just have to know the difference there otherwise there could be some issues but pull up your you know your supervision guideline in the the discussion I gave you under the Medicare policy manual that way you have a list they actually give you some examples and it can just help you when you're trying to figure out okay what does this fall under so that I'm accurate so my coding question today talks about a review of systems issue that I want to talk about that happens all the time when I'm giving education and when I explain it to the doctors and the way I'm going to explain it to you if you're if you're auditing your E&M medical record and you're seeing a lot of fours and fives level fours and fives on the new patient visit or level five and established or level three on the hospital admissions anything like that or a level five or four on a consult you're going to run into this and if this could be a huge difference in what is a complete review of systems to hit that comprehensive area versus what isn't complete and that would down code your code so I just want to make sure that you're you're clear on what we're talking about but first I also want to thank Trident University training is a leading online university serving members of the military veterans and corporate tried it dot e-d-u okay so the question came in and it came in from one of my Dubrow Nebraska subscribers when a cardiologist includes a statement like a 10-point R OS which is review systems was negative in the exam note can we count a complete review of systems the answer for that is no so reporting as negative any number of systems fewer than 14 does not satisfy the abbreviated notation requirement for review systems when you're determining the appropriate E&M service level so a complete review systems means that the physician reviewed all 14 systems but ing to the 95 and 97 nm documentation guidelines if the physician reviews and individually documents 10-plus systems with a positive or pertinent negative response as responses then you are allowed to use a statement such as an all other systems are negative that way you can claim your review of systems so a combination 10 documented all others negative that's clearly a complete review of systems but the confusion I'm finding lies that sometimes the the coders will confuse these two facts and include that a statement such as the one you know that my question person cited fulfills the complete review of system and it doesn't because it doesn't identify which 10 system the physician reviewed so also using words like non-contributory that can confuse the issue as well because it suggests that there were positive answers that just weren't recorded because the physician felt they weren't necessary for the presenting problem which is wrong so do this ensure that the physician documents all positive review systems and any pertinent negative review systems if the documentation includes at least 10 systems and this surgeon or physician also states that the remaining systems are negative then you can claim or complete review systems otherwise you have to look at all 14 okay so as we conclude for today I wanted to just end with as my usual personal note about myself today so I've been doing some Christmas shopping and having a lot of fun with that and I've been finding some some really fun things for people but one of the things I found I think that I was most excited about where was a site that actually does these bracelets and they're just they're called mantra bracelets and they're they're metal and they have rose gold and silver plated and gold plated and so they're you know anybody has a really small wrist they're great for you anybody that has a larger wrist like myself they're great for me as well and they just they they're just so pretty and inexpensive but they have words on them like truth or beautiful or smart or love you more another one was best day ever and I got a few for my daughter she doesn't listen to my code cast because she says that it doesn't talk about anything that has to do with the e-channel and the entertainment industry so she won't hear this and I swear our adult children but I give this too I gave one to one of my friends and because she was having a bad day one day and she was just like I just feel gross and I feel this and that and she's quite the the person I just I really love this person and KB shoutout to you and I gave her one that just said beautiful on it because I wanted her to look down on it and every time she was feeling that way just to you know say no I am beautiful inside and out and so hopefully you take a look again mantra bracelets and I'm not sponsored by them so this is not a this is not a plug for them it's just it was just a cool site and Instagram is taunting me for those of you out there if social medias get all those ads and I see everyone saw some things and I love personalized stuff for other people I actually am not big on it for myself but I like it for other people so how funny is that but if you're out there shopping and you want something gets to you really fast that would be one thing to take a look at also we're gonna have an updated schedule on my website for webinars for 2019 Terri Fletcher dotnet make sure you're taking a look at that we will get the NPP on the schedule for the mid-levels and I know everybody's interested in that some telemedicine telehealth to describe all of the new information and if you just need a rundown of what's happening with Medicare I give you a lot of tidbits here and there but we have a pretty big webinar coming up on that and then some specialty classes so make sure you take a look and the hope that's that's what we're gonna wrap it up with today everybody so have a great rest of your week and make it a great day and thanks again for listening to the podcast podcast for more information on medical coding billing auditing and compliance including how to hire Terri follow Terri on Twitter at Terri coder one or visit her website at WWF le tche our net podcast producer Joe Kuzma music producer de Sasson music [Music]