1. October 20101Thomas J. Weida, M.D.

2. October 2010Thomas J. Weida, M.D.2 Thomas Weida, M.D. Professor Family and Community Medicine Penn State College of Medicine CASH FOR CPT CLUNKERS

3. October 2010Thomas J. Weida, M.D.3

4. October 2010Thomas J. Weida, M.D.4 1. 99201 2. 99202 3. 99203 4. 99204 5. 99205 6. 99211 7. 99212 8. 99213 9. 99214 10. 99215

5. October 2010Thomas J. Weida, M.D.5  New: A patient 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.  Established: A patient who has been seen within the past three years. New > Three Years

6. October 2010Thomas J. Weida, M.D.6 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

7. October 2010Thomas J. Weida, M.D.7  Afraid of over coding and audit  Takes too much time to document  Don’t understand system  Too complex  Base coding on length of visit  Charge does not seem reasonable

8. None October 2010Thomas J. Weida, M.D.8 Coding Captures What You Did, Not Reimbursement

9. October 2010Thomas J. Weida, M.D.9 Element9921199212992139921499215 CCNARequired HPINA1-3 4+ ROSN/ANAPertinent2-910 PFSHN/A NA1 of 31of each ExamNAFocusedExpandedDetailedComp Dx/MgtNAMinimalLimitedMultipleExtensive DataNAMinimalLimitedModerateExtensive RiskNAMinimalLowModerateHigh Hx Px Decision Making location quality severity duration timing context modify fct assoc sx 2 of 3 One self limited problem 2 Minor self limited problems One stable chronic problem Acute simple illness OTC Drug, PT, OT, Minor surg IV no additives 1 or > chronic problem with progression or side effect 2 Stable Chronic Illnesses Undx new problem, uncertain px Acute complicated injury Prescription drug 1 or > chronic with severe exacerbation Threat to life or function Abrupt neuro change Parenteral controlled sub. Major surgery Rx with intensive monitoring PennState Hershey Medical Center 2 of 3

10. October 2010Thomas J. Weida, M.D.10 Element9920199202992039920499205 CCRequired HPI1-3 4+ ROSN/APertinent2-910 PFSHN/A 1 of 31 of each ExamFocusedExpandedDetailedComp Dx/MgtMinimal LimitedMultipleExtensive DataMinimal LimitedModerateExtensive RiskMinimal LowModerateHigh Hx Px Decision Making location quality severity duration timing context modify fct assoc sx 2 of 3 One self limited problem 2 Minor self limited problems One stable chronic problem Acute simple illness OTC Drug, PT, OT, Minor surg IV no additives 1 or > chronic problem with progression or side effect 2 Stable Chronic Illnesses Undx new problem, uncertain px Acute complicated injury Prescription drug 1 or > chronic with severe exacerbation Threat to life or function Abrupt neuro change Parenteral controlled sub. Major surgery Rx with intensive monitoring PennState Hershey Medical Center 3 of 3

11. October 2010Thomas J. Weida, M.D.11 ProblemPoints Self limited or minor (maximum of 2)1 each Established problem, stable or improving1 each Established problem, worsening2 each New problem, no additional work up planned (maximum of 1)3 New problem, with additional work up planned4

12. Data ReviewedPoints Review or order clinical laboratory tests1 Review or order radiology tests (except echo or heart cath)1 Review or order medicine test (PFT, EKG, Cardiac Cath, Echo, etc. *)1 Discuss test with performing physician1 Independent review of tracing, image or specimen (i.e. EKG, KOH)2 Decision to obtain old records1 Review and summation of old records2 October 2010Thomas J. Weida, M.D.12 * EKGs, EEGs, PFTs, echocardiograms, cardiac catheterizations, cardiac stress tests, audiometry, speech or swallow studies, pacemaker interrogations, arterial or venous doppler studies, plethysmography, non-invasive arterial studies (such as ABIs), transcranial doppler studies, allergy testing, sleep studies, EMGs, evoked potentials, tensilon testing and nutritional assessments

13. RiskPresenting Problems Diagnostic OptionsManagement Options Minimal (992x2) MinimalRoutine Labs, EKG, X-rays, USN, Echo, EEG Advice Low (992x3) LowPFT, Contrast X-rays, ABG, Skin Biopsy OTC, PT, OT, Minor Surgery, IV – no additives Moderate (992x4) MediumStress tests, endoscopies, Cardiac cath, LP, Thoracentesis Prescription Drugs, IV’s with additives, Major surgery – no risk factors, Minor surgery with risk, Closed fracture, Nuclear med treatment High (992x5) HighCardiovasc imaging with risk factors, EP studies, Endoscopy with risk, Discography Surgery with risk, Emergency surgery, Narcotics, Drug therapy with extensive monitoring, DNR decision October 2010Thomas J. Weida, M.D.13

14. Overall MDMProblem Points Data Points Level of Risk Straightforward Complexity (992x2) 11Minimal Low Complexity (992x3) 22Low Moderate Complexity (992x4) 33Moderate High Complexity (992x5) 44High October 2010Thomas J. Weida, M.D.14 Need Two of Three to Qualify for Level

15. October 2010Thomas J. Weida, M.D.15  Don’t forget to include it

16. October 2010Thomas J. Weida, M.D.16  Physician must record chief complaint and HPI  Staff may record past medical, social and family history.  Staff may record review of systems.  Intake sheet can be used instead of staff asking questions for ROS & PFSH.

17. October 2010Thomas J. Weida, M.D.17

18. October 2010Thomas J. Weida, M.D.18

19. October 2010Thomas J. Weida, M.D.19 http://www.aafp.org/fpm/20060900emvisit.pdf

20. October 2010Thomas J. Weida, M.D.20  The specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances.  Face-to-face for office and outpatient  Unit/floor for hospital and inpatient  Time is not a criteria for level of service.

21.  Your real or electronic signature is a critical component of the note  Audits this year focusing on signatures October 2010Thomas J. Weida, M.D.21

22.  CC: Abdominal Pain  HPI: 45 y/o female with 2 day history of constant, RLQ abdominal pain, 6/10 in intensity, which started after dinner, made worse by movement, and accompanied today by fever.  PFSH updated and reviewed on summary  ROS # of items reviewed per intake form October 2010Thomas J. Weida, M.D.22

23. October 2010Thomas J. Weida, M.D.23  1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment  Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)  Abrupt neuro status change (TIA, Sx, weakness, sensory loss)  4 HPI elements  10 ROS  1 of each PFSH  Comprehensive (general multisystem or complete single organ) Decision Making History Physical 40 min

24. October 2010Thomas J. Weida, M.D.24  1 chronic illness with exacerbation  2+ or more chronic stable illnesses  Undiagnosed new problem with uncertain diagnosis  Acute illness with systemic symptoms  Acute complicated injury  4 HPI elements  2-9 ROS  1 of 3 PFSH  Detailed (affected area and related organ system) Decision Making History Physical 25 min

25. October 2010Thomas J. Weida, M.D.25  2 or more self limited problems  one stable chronic illness  acute uncomplicated illness (cystitis, sprain)  1-3 HPI elements  Pertinent ROS  Expanded problem focused Decision Making History Physical 15 min

26. October 2010Thomas J. Weida, M.D.26  1 or more chronic illness with severe exacerbation, progression or side effects of treatment  Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)  Abrupt neuro status change (TIA, Sx, weakness, sensory loss)  4 HPI elements  10 ROS  1 of each PFSH  Comprehensive (general multisystem or complete single organ) Decision Making History Physical 60 min

27. October 2010Thomas J. Weida, M.D.27  1 chronic illness with exacerbation  2+ or more chronic stable illnesses  Undiagnosed new problem with uncertain diagnosis  Acute illness with systemic symptoms  Acute complicated injury  4 HPI elements  10 ROS  1 of each PFSH  Comprehensive (general multisystem or complete single organ) Decision Making History Physical Looks like a 215 45 min

28. October 2010Thomas J. Weida, M.D.28  2 or more self limited problems  one stable chronic illness  acute uncomplicated illness (cystitis, sprain)  4 HPI elements  2-9 ROS  1 of 3 PFSH  Detailed (affected area and related organ system) Decision Making History Physical Looks like a 214 30 min

29. October 2010Thomas J. Weida, M.D.29 20 min 10 min  One self limited problem  Focused exam  1-3 HPI elements  One self limited problem  Expanded problem focused exam  1-3 HPI elements  Pertinent ROS

30. October 2010Thomas J. Weida, M.D.30  BP check by nurse  Weight check for CHF  Lab draw  Picking up prescription refill  Picking up return to work or school certificate. (If mail or call in, no CPT code allowed)  May not require physician presence 5 min “Coding from the Bottom Up,” Thomas Weida, David O’Gurek, Family Practice Management, November 2008

31. October 2010Thomas J. Weida, M.D.31

32. October 2010Thomas J. Weida, M.D.32 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

33. October 2010Thomas J. Weida, M.D.33 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

34. October 2010Thomas J. Weida, M.D.34 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

35. October 2010Thomas J. Weida, M.D.35 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215 Overall MDMProblem Points Data Points Level of Risk Straightforward Complexity (992x2) 11Minimal Low Complexity (992x3) 22Low Moderate Complexity (992x4) 33Moderate High Complexity (992x5) 44High ProblemPoints Self limited or minor (maximum of 2)1 each Established problem, stable or improving1 each Established problem, worsening2 each New problem, no additional work up planned (maximum of 1)3 New problem, with additional work up planned4

36. October 2010Thomas J. Weida, M.D.36 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

37. October 2010Thomas J. Weida, M.D.37 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215 6. No Charge

38. October 2010Thomas J. Weida, M.D.38 1. 99201 2. 99202 3. 99203 4. 99204 5. 99205 Medical decision making of 99214 History and physical of 99215

39. October 2010Thomas J. Weida, M.D.39 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

40. October 2010Thomas J. Weida, M.D.40 1. 99201 2. 99202 3. 99203 4. 99204 5. 99205

41. October 2010Thomas J. Weida, M.D.41 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

42. October 2010Thomas J. Weida, M.D.42 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

43. October 2010Thomas J. Weida, M.D.43 1. 99211 2. 99212 3. 99213 4. 99214 5. 99215

44. October 2010Thomas J. Weida, M.D.44  Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service  Best to have two different diagnoses  E&M -25 and procedure code  Document two independent notes CPT 2000, pg. 403-404

45. October 2010Thomas J. Weida, M.D.45  If, during a preventive medical service (99381-99387, 99391-99397) the patient presents with a separately identifiable problem significant enough to require additional work, can bill a E/M code with modifier –25.  Use two separate diagnosis: V70.0 or V20.2 for preventive visit and a medical diagnosis.  Do two separate notes.

46. October 2010Thomas J. Weida, M.D.46  Strains requiring additional workup  Infections requiring prescription  Conditions referred to a specialist  Chronic conditions with changed treatment

47. October 2010Thomas J. Weida, M.D.47  Rash not requiring prescription or workup  Bump that is normal  Chronic condition that has not changed and no change to treatment plan is warranted

48. October 2010Thomas J. Weida, M.D.48  Code 99080  Establish a charge you will use  Need to develop policy and process on billing for form completion.  Who charges?  What are the exceptions?  When is fee collected?  Patient Education.

49. October 2010Thomas J. Weida, M.D.49  99406 - Smoke/Tobacco Counseling 3-10 min  99407 - Smoke/Tobacco Counseling > 10 min  8 visits annually allowed in 12 mo period (4 sessions per attempt)  E/M service on same day, use modifier -25

50. October 2010Thomas J. Weida, M.D.50  305.1 Tobacco Use Disorder  V15.82 History of Tobacco Use  No longer need to provide other clinically relevant diagnosis code, such as cough 786.2  Document time spent counseling regarding tobacco cessation

51. October 2010Thomas J. Weida, M.D.51  99221: Ave 30 min bedside or floor  Decision making – low complexity  Detailed history, detailed physical  99222: Ave 50 min bedside or floor  Decision making moderate complexity  Comprehensive history, comprehensive physical  99223: Ave 70 min bedside or floor  Decision making of high complexity  Comprehensive history, comprehensive physical

52. October 2010Thomas J. Weida, M.D.52  Initial hospital visit for 14 year old female with infectious mononucleosis and dehydration. 1. 99221 2. 99222 3. 99223 99221

53. October 2010Thomas J. Weida, M.D.53  Initial hospital visit for a healthy 24 year old male with an acute onset of low back pain following a lifting injury. 1. 99221 2. 99222 3. 99223 99221

54. October 2010Thomas J. Weida, M.D.54  Initial hospital visit for a 61 year old male with history of previous myocardial infarction, who now complains of chest pain. 1. 99221 2. 99222 3. 99223 99222

55. October 2010Thomas J. Weida, M.D.55  Initial hospital visit for a 50 year old male with acute chest pain and diagnostic electrocardiographic changes of an acute anterior myocardial infarction. 1. 99221 2. 99222 3. 99223 99223

56. October 2010Thomas J. Weida, M.D.56  Initial hospital visit for a 65 year old female for acute onset of thrombotic cerebrovascular accident with contralateral paralysis and aphasia 1. 99221 2. 99222 3. 99223 99222

57. October 2010Thomas J. Weida, M.D.57  Initial hospital visit for a 70 year old male admitted with chest pain, complete heart block, and congestive heart failure. 1. 99221 2. 99222 3. 99223 99223

58. October 2010Thomas J. Weida, M.D.58  Hospital admission of a 62 year old smoker, established patient, with bronchitis in acute respiratory distress. 1. 99221 2. 99222 3. 99223 99222

59. October 2010Thomas J. Weida, M.D.59  Initial hospital visit for a 73 year old female with acute pyelonephritis who is otherwise generally healthy. 1. 99221 2. 99222 3. 99223 99221

60. October 2010Thomas J. Weida, M.D.60  Initial hospital visit for a 78 year old male, transfers from nursing home with dysuria,and pyuria, increasing confusion, and high fever. 1. 99221 2. 99222 3. 99223 99223

61. October 2010Thomas J. Weida, M.D.61  Hospital admission, examination, and initiation of treatment program for a 67 year old male with uncomplicated pneumonia who requires IV antibiotic therapy. 1. 99221 2. 99222 3. 99223 99221

62. October 2010Thomas J. Weida, M.D.62  Initial hospital visit for a young adult, presenting with an acute asthma attack unresponsive to outpatient therapy. 1. 99221 2. 99222 3. 99223 99222

63. October 2010Thomas J. Weida, M.D.63  Hospital admission for a 78 year old female with left lower lobe pneumonia and a history of coronary artery disease, congestive heart failure, osteoarthritis and gout. 1. 99221 2. 99222 3. 99223 99223

64. October 2010Thomas J. Weida, M.D.64  99231: Patient is stable, recovering or improving.  Average of 15 minutes.  2 of 3 Key Components  Decision making: Low Complexity  Problem focused interval history  Problem focused physical

65. October 2010Thomas J. Weida, M.D.65  99232 – Patient is not responding to treatment or has developed a minor complication.  Average of 25 minutes.  2 of 3 Key Components  Decision making: Moderate Complexity  Expanded problem focused interval history  Expanded problem focused interval physical

66. October 2010Thomas J. Weida, M.D.66  99233 – Patient is unstable or has developed a significant complication or a significant new problem.  Average of 35 minutes.  2 of 3 Key Components  Decision making: High Complexity  Detailed interval history  Detailed interval physical

67. October 2010Thomas J. Weida, M.D.67  Subsequent hospital visit for a 76 year old male with venous stasis ulcers. 1. 99231 2. 99232 3. 99233 99231

68. October 2010Thomas J. Weida, M.D.68  Subsequent hospital visit for 13 year old male admitted with left lower quadrant abdominal pain and fever, not responding to therapy. 1. 99231 2. 99232 3. 99233 99232

69. October 2010Thomas J. Weida, M.D.69  Subsequent hospital visit for a 62 year old patient with resolving cellulitis of the foot. 1. 99231 2. 99232 3. 99233 99231

70. October 2010Thomas J. Weida, M.D.70  Subsequent hospital visit for a 67 year old female admitted three days ago with bleeding gastric ulcer, now stable. 1. 99231 2. 99232 3. 99233 99231

71. October 2010Thomas J. Weida, M.D.71  Subsequent hospital visit for a 50 year old male, post CABG, now develops hypotension and oliguria. 1. 99231 2. 99232 3. 99233 99233

72. October 2010Thomas J. Weida, M.D.72  Subsequent hospital visit for a 54 year old female admitted for myocardial infarction, but who is now having frequent premature ventricular contractions. 1. 99231 2. 99232 3. 99233 99232

73. October 2010Thomas J. Weida, M.D.73  Subsequent hospital visit for a patient with venous stasis ulcers who developed fever and red streaks adjacent to the ulcer. 1. 99231 2. 99232 3. 99233 99232

74. October 2010Thomas J. Weida, M.D.74  Subsequent hospital care for a 62 year old female with congestive heart failure, who remains dyspneic and febrile. 1. 99231 2. 99232 3. 99233 99232

75. October 2010Thomas J. Weida, M.D.75  Subsequent hospital visit for 65 year old male with acute myocardial infarction who now demonstrates complete heart block and congestive heart failure. 1. 99231 2. 99232 3. 99233 99233

76. October 2010Thomas J. Weida, M.D.76  Subsequent hospital visit for an 18 year old male with uncomplicated asthma who is clinically stable. 1. 99231 2. 99232 3. 99233 99231

77. October 2010Thomas J. Weida, M.D.77  1 chronic illness with exacerbation  2+ or more chronic stable illnesses  Undiagnosed new problem with uncertain diagnosis  Acute illness with systemic symptoms  Acute complicated injury

78. October 2010Thomas J. Weida, M.D.78 1. 0 2. 1 3. 2 4. 3 5. 4 6. 5 – 7 7. > 8

79.  Pull 10 notes and check coding against easy to use guidelines.  Mentally calculate how much revenue lost  Kick self  Repeat process till no longer kicking self  Simple October 2010Thomas J. Weida, M.D.79 CPT Simplicity