CPT Coding: Beyond the Basics

CPT Coding: Beyond the Basics
AANP NATIONAL CONFERENCE 2010 Barb Pierce, CCS-P, ACS-EM Barb Pierce Coding and Consulting, LLC Barb Pierce, CCS-P, ACS-EM

Barb Pierce, CCS-P, ACS-EM
Objectives Review the overall billing process, including CPT, HCPCS, and ICD-9 coding systems 30 minutes Review the codes used on a daily basis 90 minutes Review surgical coding, proper use of modifiers and other coding concepts 60 minutes Barb Pierce, CCS-P, ACS-EM

Outline E/M codes Office, hospital, consultations, preventive medicine Injections and immunizations Lacerations, lesions and other minor surgical procedures Modifiers ICD-9 coding and linking Coding for compliance Barb Pierce, CCS-P, ACS-EM

The codes CPT Main coding system that describes what was done HCPCS Further specification of some CPT codes, including supplies ICD-9 Describe why the service was performed, diagnostic statement Barb Pierce, CCS-P, ACS-EM

Billing the codes The “what” and the “why” need to be linked and must meet medical necessity The encounter form (superbill) needs match the information in the medical record Barb Pierce, CCS-P, ACS-EM

Billing for the Provider
Billing rules for the Nurse Practitioner Own number Incident to Medicare versus everybody else Split/shared visits Consultations Barb Pierce, CCS-P, ACS-EM

E/M Coding New vs. established and initial vs. subsequent What is a new patient? Determined by site of service Follow the HCFA/AMA Documentation Guidelines to choose the level Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

New vs. Est Patients Per CPT: Solely for purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). Cardiologist read an EKG on a patient a year ago without a face-to-face visit. NP in same group sees the patient on 1/15/10. New patient Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

New vs. Est Patient Per CPT: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Dr. FP1 saw the patient for bronchitis six months ago. NP is now seeing the patient for abdominal pain. Established patient to Dr. FP2 Dr. Heart (general cardiology) saw the patient for HTN six months ago. Now the patient is seeing Dr. Vessel (interventional cardiology) for coronary artery blockage six months later. Established patient to Dr. Vessel Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

New vs. Est Patient Watch for specialty designations, as recognized by Medicare Example on previous slide, no different specialty designation for Dr. Heart and Dr. Vessel Dr. Podiatry and Dr. Back in the same Ortho group. These are recognized as different specialties according to Medicare. So, if Dr. Podiatry saw the patient within the past 3 years and now Dr. Back is seeing the patient, Dr. Back could bill a new patient visit. Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

E/M Section Key components History Examination Medical Decision Making Some require 3/3 Some require 2/3 Coding by time instead Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Office/Other outpatient services
Codes don’t crosswalk, i.e compared to 99203 Office and where else? 99211 … be careful Hints for construction of encounter form Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Consultations 2010 … CPT A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source. The consultant’s opinion and any services that were ordered or performed must be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. Still cautioned about transfer of care Billing for consultations based on new wording “on the unit” Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Consultations 2010 … Medicare
Medicare has decided not to pay for consultations starting in Instead the RVU’s have been reallocated and increased for the other visit codes. Office, use new or established patient visit codes (3 yr rule will apply) Hospital and Nursing Facility, use admission codes Office: Codes formerly used for consultation services – crosswalk exactly with documentation requirements of – If patient seen in last 3 years by physician of same group of same specialty, then use – Hospital and Nursing Facility: Codes formerly used for consultation services – do not crosswalk with admission codes (5 levels of consults versus 3 levels of admissions) Barb Pierce Coding and Consulting, LLC Barb Pierce, CCS-P, ACS-EM

Observation codes Based on patient status Admit to OBS Discharge from OBS What if patient is held in OBS for 3 calendar days? Admit and discharge from OBS same date Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Medicare Coding for OBS patients
Consultations for patients in OBS status The ordering physician for the OBS status will use the OBS admission codes – 99220 The “specialist” will use the outpatient visit codes – 99215 Three year rule will apply Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Inpatient Services Admission H/E/MDM similar to 3,4,5 new patient/consult codes admission from the office…bill the office visit or the initial hospital care? daily visits without an initial hospital code first Admit/discharge same date: Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Inpatient Admissions 99221 requires Detailed history and Detailed exam and Straightforward medical decision making 99222 requires Comprehensive history and Comprehensive exam and Moderate medical decision making 99223 requires High medical decision making Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Hospital Admissions No three-year rule For Medicare, the admission code will be billed by the “physician-formerly-known-as-a-consultant” per hospital admission. Multiple physicians may be billing the – on the same patient. Admitting physician of record will use modifier -AI. Oncologist saw the Medicare patient during an admission six weeks ago. The patient is admitted again, the oncologist is “consulted” again (for the same or a different problem). Oncologist bills Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Inpatient Admissions CPT’s intent of – 99223: Report the first hospital inpatient encounter Not necessarily the date of admission Not used if patient seen subsequently that date and discharged New for 2010, these are the codes recognized by Medicare for all physicians seeing the patient for the first time during a hospital stay Used in place of consultation codes If documentation is less than documentation requirements for 99221, use the unlisted code or subsequent hospital visit code – Admitting physician of record will use modifier -AI Diagnosis coding issues … medical necessity will prevail Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM 20

Modifier for Admitting Physician of Record
What modifier should the admitting physician of record use? AI is a new HCPCS modifier for “principal physician of record” Informational modifier Specialist claims should not be held up if admitting physician of record forgets to use the AI If AI is used unnecessarily, claims should not deny … no edit in place currently Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Inpatient Services Subsequent hospital care Only need 2/3 key components Can’t bill for more than one/day Code by time when appropriate Discharge: or based on time…and what is included in that time Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Inpatient Discharge 99238 Discharge day management, 30 minutes or less 99239 Discharge day management, more than 30 minutes Documentation must indicate that >30 minutes spent and why Includes: Final evaluation of the patient Discussion of hospital stay Instructions (may include caregivers) Preparing discharge records, prescriptions and referral forms Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

OBS or Inpatient Care - Admit and Discharge Same Date
Same calendar date Can be used for OBS or inpatients Medicare guidelines require that the patient be there at least 8 hours if using these codes and provider must document that fact Patient could be inpatient status or OBS status … codes are the same, place of service would be different 99234, 99235, or (same criteria for history, examination, and MDM as other admission codes) Require two face-to-face visits Why? The RVU for these codes = admit + discharge Face-to-face for one and phone call for other won’t work If only seen once, then bill for the service rendered, which might be the admit (inpatient or OBS) or it might be the discharge Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Nursing Facility services
Nursing Facility Codes Include SNF, even if bed located in hospital setting Don’t forget the discharge codes based on time Hospital discharge and nursing facility admission on same date IF both services meet criteria For Medicare, the service formerly reported as a consultation will now be reported as an admission to the facility. Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Domiciliary Services Facilities without a medical component Can be used for Assisted Living facilities Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Emergency Department codes
“organized hospital-based facility”…must be available 24 hours a day Five levels with different criteria than office visits Can’t code by time Specialists should used consultation codes instead, if criteria met (except for Medicare) Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

ER Visits 99281 – 99285 Codes usually used by the provider assigned to the ER Could be possible for more than one provider to use this code on same patient But … probably a consultation or office/out-patient service instead However, for Medicare, multiple physicians are to use the ER codes (in place of consultation codes) Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Medicare Resources Prolonged Services MLN Matters MM5972 7/1/08 Critical Care MLN Matters MM5993 7/7/08 Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Preventive Medicine When considering the billing options for preventive medicine, we must keep in mind: We intend to submit accurate information to health insurers. We will not misrepresent the nature or purpose of encounters in order to receive insurance reimbursement. Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Preventive Medicine When an appointment is scheduled, attempt to determine the nature of the visit so as to allow adequate time for the service. Patient education could occur at that time. Are you going to take care of everything today and split bill? Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

PM with E/M Define “additional work” E/M codes require a chief complaint and history of present illness From an auditing standpoint, expect additional history and medical decision making Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

CPT Codes are for preventive medicine services are defined by the patient’s age in two categories: new or established require comprehensive history and comprehensive examination (but not same definition as comprehensive in E/M Documentation Guidelines) Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

MEDICARE P/P/B Medicare will pay every two years for a screening pap, pelvic and breast exam for females at low risk G0101 is for the pelvic and breast exam, requires 7/11 elements on exam Q0091 is for collection of Pap smear Paid yearly for patients at high risk Can bill E/M-25, G and Q on same date Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

G and Q Use ICD-9 codes V76.2, V76.47, or V76.49 for patients at low risk Each ones pays $ Paid every two years for low risk If unsure when patient last had these services, get an ABN signed and use -GA modifier Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

E/M, G, and Q Document and code the E/M service at the appropriate level based on history, exam and decision making. Modifier -25 and diagnosis(es) for problems addressed Bill the G0101 and Q0091 additionally with V code as diagnosis Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Medicare Carve Out 99397 9921X-25 G0101 Q0091 (?) Any combination of above, based on documentation Patient pays minus Medicare allowed services Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

What about the guys?? Medicare digital rectal exam G0102 Medicare PSA G0103 Here’s the good news: both are paid yearly Here’s the bad news: both are bundled with E/M code if done on same day Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Other preventive medicine services
Other than these E/M services, Medicare also pays for other screening, preventive services. Research your Medicare bulletins Welcome to Medicare Physical Much better with 2009 changes Some screening labs for diabetes and cardiovascular disease Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

E/M Documentation Guidelines
Barb Pierce, CCS-P

E/M Coding and Auditing
Documentation must support the level of service billed Service performed vs. level billed vs. level documented 95 vs. 97 Documentation Guidelines Barb Pierce, CCS-P

General Principles Record must be complete and legible
Even the signature or identification Record stands on its own…but can incorporate by reference Signature log Barb Pierce, CCS-P

3/3 or 2/3 ?? Key components = history, examination, and medical decision making New patient visits, consultations, hospital admits require 3/3 Established patient visits, daily hospital care require 2/3 Barb Pierce, CCS-P

History ROS and PFSH can be incorporated by reference by reviewing and updating prior information, noting the date and location of earlier information…but not HPI Can also incorporate by reference information recorded by ancillary staff or patient If unable to get history, say why “all others negative” “noncontributory” Barb Pierce, CCS-P

Examination 1995 guidelines are more generic by body system
How do you apply the ’95 exam criteria? 1997 guidelines are very specific..the “bullets” numeric requirements must be met parenthetical examples are for clarification and guidance only “and” really means “or” Barb Pierce, CCS-P

Medical Decision Making
Based on the average of : number of diagnoses/management options data to be ordered/reviewed risk (nature of presenting problem, diagnostic procedures, management options) Barb Pierce, CCS-P

Medicine Section Immunizations and injections require 2 codes: the administration and the supply 96372 with J code (watch for units) 90471 for one vaccine 90472 for each additional vaccine code the actual vaccine additionally Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Surgery Section Global surgery package includes pre-op day(s) and post-op days Medicare Fee Schedule is good resource…some minor procedures have a post-op period Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Surgery Section Separate procedure designation … code only if it is the only procedure done. Example: exploratory laparotomy Bundled with more extensive procedure May be the approach Watch for CCI edits (Correct Coding Initiative) which bundle certain services Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

CCI Edits Published by NTIS and updated quarterly Other resources may include other coding standards Misuse of Column 2 with Column 1 20550 Injection tendon sheath is a therapeutic injection. If (removal of foreign body) is done, it would be a misuse if code is billed to represent injection of local anesthesia to do the 20520 Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Coding Edits Surgical package and separate procedure concepts Designation of sex Family of codes Most extensive procedure: simple/complex, superficial/deep, incomplete/complete Sequential procedures With/without Mutually exclusive Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Surgery Section Lacerations Need location, size, type of repair (simple, intermediate, complex) Add laceration lengths if same type of repair and same anatomical site Have the provider be specific on the encounter form Additional E/M only if significant, separately identifiable services done, then add -25 Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Surgery Section Lesions Need location, size, type of removal or destruction Lesion size vs. excised size Destruction codes changed for 2007 May need a special lesion removal charge ticket For removals, hold for path report to determine if benign or malignant Don’t rely on path report for size or number of lesions Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Surgery Section Fracture care codes Global periods Bill casting materials additionally Re-casting can be billed additionally Casting or splinting can be billed if done to stabilize Medicare has special Q codes (HCPCS) for splint and cast supplies Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

OB Maternity care and delivery should be billed as a global OB package unless you only did part of the OB care Antepartum care (code based on number of visits) Delivery (different codes vaginal delivery vs. cesarean delivery) Postpartum care No special codes for high risk. Bill additional E/M codes separately “package” may vary by insurance company Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Medicare Physician Fee Schedule Data Base - MPFSDB
Indicator list Gives information about specific codes Updates quarterly by CMS Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifier –24 Unrelated E&M service
E&M service by the same physician during a postoperative period for condition not related to surgery Global periods of 0-10 and 90 days Individual payers define postoperative period Diagnosis code identifies the reason for the E&M as unrelated to the procedure Informational modifier - claim gets paid Examples Barb Pierce, CCS-P, ACS-EM

Modifier -25 Modifier -25 Indicates a significant, separately identifiable E/M service by the same physician on the same day as another procedure or service Use on E/M code Examples Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifier –26 Professional Component
Professional portion for procedures that are a combination of professional and technical components Provider must prepare a written report Medicare fee schedule P/T column Appropriate to use -26 modifier Global code - payment for both components -26 Payment for professional component -TC Payment for technical component Check indicator number for P/T Barb Pierce, CCS-P, ACS-EM

Modifier -50 50- Bilateral procedure Indicates bilateral procedures performed during same operative session Verify if code description states procedure is bilateral Payment based on 150% of fee schedule Use one line item with # of services “1” Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifier -51 51- Multiple procedures Indicator 0- does not apply- do not use 51 Indicator 2- does apply( 100%, 50%, 50% etc.) Indicator 3- special endoscopy rules apply if billed with another endoscopy code. Indicator 9- does not apply- do not use 51 Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifier -57 Modifier -57 Decision for surgery with supporting documentation Use on E/M code to keep it out of the global package Applies to major procedures for scopes and procedures with 10 day global, use -25 modifier instead (especially Medicare) Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifier -59 Modifier -59 Used to identify procedures or services that are normally reported together, but need to indicate a particular circumstance such as different encounter, different procedure, different site Modifier of last resort Will bypass CCI edit…should not be used routinely to bypass the edit Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

CCI cont. 59- Distinct procedural service Separate encounter, different site/organ system, separate injury, procedures performed on same day by same physician Appropriate under certain circumstances Example 02/15/ destruction of lesion hand 02/15/ biopsy of arm Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

ICD-9 Coding ICD-9-CM codes describe “why” the service was performed Be specific !!! Always confirm the code Code what you know at the time the service is performed…signs and symptoms are okay Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

ICD-9 Coding There are two volumes…use both !! Note the main terms Use the alpha index to locate main term Look for modifiers, subterms, notes and cross-references Select a tentative code Confirm in the tabular Code to the highest level of specificity Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

ICD-9 Abbreviations NEC: Not elsewhere classifiable means the coding system limits the code selection, such as “other” NOS: Not otherwise specified means the documentation was unspecified Is there more specific information available? Develop a “hit list” of unspecified codes Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

ICD-9 Unspecified codes
Diabetes Musculoskeletal diagnoses or symptoms without a specific location Hypertension Illnesses that are acute or chronic Others??? Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Coding Signs & Symptoms
Definitive diagnosis not available Possible, probable, rule out Used widely in primary care Check out Chapter 16 which includes many signs, symptoms, and ill-defined conditions. Also the location for abnormal test result codes Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

V Codes Describe a reason for the encounter without active illness Personal history and family history of malignant neoplasms V codes are our friends and can be used as the primary code Codes for preventive medicine services Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

V Codes Look for terms such as: admission, examination, problem with, aftercare, history of, screening for, supervision of, attention to, observation for, status (or status post) Pre-op evaluations: V72.8_ Personal and family history of malignant neoplasms: V10 and V16 codes Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Diagnosis Code Linking
Helps identify medical necessity Helps justify the reason for the CPT code Multiple codes present challenges…who links? Does your encounter form allow for linking? LCD’s, NCD’s, and ABN’s ICD-10 Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Waiver or not? Screening tests - no waiver if due to statutory exclusion Screening tests - waiver if sometimes payable (frequency) Tests not meeting medical necessity criteria require the waiver Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Modifiers for ABN situations
GY: item or service statutorily excluded or does not meet definition of any Medicare benefit (will result in denial) GZ: item or service expected to be denied as not reasonable and necessary…without ABN signed GA: ABN signed and on file Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Compliance Work your compliance plan Education Monitoring Correction Internal reviews External reviews Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Patient, Physician and Staff Education
Patients need to understand the rules Use information provided by the carrier Make sure staff know the rules Let physicians know how they can help Create policies and procedures Use carrier provided patient education Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Areas to Monitor/Look for Improvement
Compare the medical record, encounter form, and CMS-1500 (or computer entry) Do all three tell the same story? Level of service for E/M Type of E/M service Provider of service Date and location of service Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Templates and other tools
History forms completed by patient or staff with past history, family history, social history, and system review Progress notes that prompt the provider of documentation requirements (and may reduce transcription costs) Build a helpful encounter form Common procedures ICD-9 codes ? Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Coding Compliance Medical necessity above all else, regardless of documented history or examination Follow incident-to rules Follow teaching rules Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Incident to Services Office only Incident to provider on site Incident to provider’s already established care plan, so no new patients or new problems PA’s and NP’s can bill this way or under their own provider numbers Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Teaching Rules Residents are individuals in an approved GME (graduate medical education) program…includes interns and fellows Carriers Manual Section … revisions Teaching physician has to document presence and participation in service Clarifications of what medical students can and cannot document Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Teaching Rules Can’t code by time Special rules for procedures…key portions Medical Students are not residents For tying into resident note, the following are NOT adequate: signature only seen and agree with signature reviewed resident’s note and agree Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Policies and Procedures/Education
99211 Procedures with E/M Use of modifiers New vs. established patients Incident-to rules Teaching rules Importance of ICD-9 coding and linking NCDs and LCDs … need for ABNs Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Keep going …. Preventive medicine and split billing Consultation codes Proper documentation of time Look at some EOB’s Barb Pierce, CCS-P, ACS-EM Barb Pierce, CCS-P, ACS-EM

Post-test Questions Preview To receive CE credit, the post-test and evaluation must be completed online at If you successfully answer at least 70% of the test items, you will be able to print a certificate. For questions or more information concerning this online CE opportunity, please contact Stormy Causey, CE Coordinator at This program provides the following Post-Test Preview as a convenience, ONLY to help in preparation for the online Post-Test. Credit is awarded for tests completed online. 1. CPT codes represent: Diagnosis Procedures Patient demographics Fees 2. CPT classifies a new patient as one who: Has never been seen by the provider Has not been seen by a member of the same group of the same specialty in three years Needs a new medical record and account established Is referred by another provider 3. The global surgery package: Applies to all CPT codes Allows you to bill for post-op office visits Includes some pre-op and post-op services Does not apply to procedures performed in the office Barb Pierce, CCS-P, ACS-EM

Post-test Questions Preview (cont.) 4. An Advanced Beneficiary Notice (ABN) is required: In situations where you believe Medicare may deny the service based on the limitations of a local or national policy On every service provided to a Medicare patient So that Medicare can bypass their edits and pay you for everything On all screening tests 5. The difference between and is: The amount of time spent taking the history Whether a PCP or specialist provided the service The fact that is reserved for new patients The amount of history, examination, and medical decision making that must be performed and documented 6. An office visit and minor procedure on the same day: Will always be paid and you won’t need a modifier Require documentation of significant and separately identifiable history, exam and/or medical decision making over and above the procedure Must be performed at two visits at separate times Cannot both be billed Barb Pierce, CCS-P, ACS-EM

Post-test Questions Preview (cont.) 7. Time overrides history, examination, and medical decision making for those patient encounters where the majority of the visit is spent counseling the patient. True False 8. Since Medicare no longer pays for consultations, patients who present to the office for a pre-operative clearance would always be coded as new patients. 9. Code G0101 is: Paid by Medicare every year The code accepted by Medicare for a screening breast exam, pelvic exam and collection of a Pap smear Never to be billed in addition to 99213 The code used to describe a digital rectal exam for males 10. If the patient presents with abdominal pain and is sent to the hospital for further testing to rule out appendicitis, the diagnosis for the office visit would be : Abdominal pain Appendicitis Barb Pierce, CCS-P, ACS-EM

CPT Coding: Beyond the Basics

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