Presentation on theme: "Coding for Local Health Department Clinic & School Sites"— Presentation transcript:
1 Coding for Local Health Department Clinic & School Sites Presented by: Cynthia H. RobinsonKentucky Department for Public HealthAFM/LHOJuly 2011
2 Table of Contents Coding on the PEF Determination of New or Established PatientsCoding of Preventive VisitsComponents for coding “Other than Preventive E/M Visits”Coding of Problem Visits – New PatientsCoding of Problem Visits – Established Patients7. Multiple Visits for the Same Patient on the Same Day
3 This presentation was done to aid employees of health department clinics in coding and reporting of services. It could not possibly cover all of the circumstances which occur in these clinics on a day to day basis. This presentation is intended to assist in the training of new employees and to refresh existing employees.
4 Guiding PrinciplesOnly provide the level of care that is medically necessary per clinical judgment.Always provide and document services in accordance with the Public Health Practice Reference and with established best practices.Always code and document exactly what care was provided.
6 Coding on the PEFThe state-updated CH-45 (PEF) is used in most health department clinics. (Shown on next slide.)Some health departments prefer to create and use an abbreviated PEF at off site clinics (e.g. Flu Clinics & School sites). This is entirely permissible.Health Departments using their own forms are responsible for keeping these forms up-to-date.
8 CodesCurrent Procedural Terminology (CPT) – A set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers.CPT codes describe WHAT was done for the patient.International Classification of Disease 9th Revision 2009 (ICD-9) – This system is required for reporting diagnoses and diseases to all U.S. Public Health Service and Department of Health and Human Services Programs, such as Medicare and Medicaid.ICD-9 codes describe WHY it was done.
9 Examples of Codes CPT codes - WHAT ICD-9 codes - WHY CLINIC SETTING: 99211– Office or other outpatient visit for the evaluation and management of an established patient that may or may not require the presence of a physician.99393 – Periodic comprehensive preventive medicine – reevaluation & management of an individual late childhood (age 5 through 11 years)SCHOOL SETTING:99212 – Office or other outpatient visit for the E/M of an established patient, which requires at least 2 of these 3 key components: History, exam, & medical decision makingV741 – Special Screening Examination For Pulmonary TuberculosisV202 - Routine Infant Or Child Health check7840 – Headache ; Facial Pain; Pain in head NOS
10 Coding E/M visits on the PEF Coding E/M visits in health department clinics consists of:Preventive Visits E/M visits (e.g. well child exam, well woman checks)Evaluation/Management visits, which LHD’s commonly refer to as “problem visits” (e.g. supply visits, STD’s, cancer screenings)
11 Coding on the PEF Preventive Visits (e.g. Well Child Exams) Top left corner of PEFfor Physicians/mid-level providersW9381-W9397 for Nurses
12 Coding on the PEF Other E/M Visits (Problem Visits) Top right corner of PEFfor Physicians/mid-level providersW9201-W9215 for Nurses
13 Coding on the PEF – Provider Level REMEMBER:992 codes - for use by physicians and mid level providers onlyW92 codes - for use by nurses (RN’s)Physicians and mid level providers code in the upper portion of the Preventive and Other Than Preventive Sections.Nurses code in the lower portion of the Preventive and Other Than Preventive Sections.
14 Coding on the PEF- CPT codes CPT codes for lab tests, etc. that are done as part of the visit must be....Checked in the appropriate box on the PEFOR, if the service is not listed on the PEF it should be written in the area provided
15 Coding on the PEF - ICD codes ICD codes need to be written on the PEF in the section that corresponds with the office visit that was checked.ICD codes will reflect why the patient presented. They are assigned based on the presenting problem(s) of the patient.REMEMBER: ICD codes for LHDs must be five digits. If the code is 3 or 4 digits, add dashes to make the code 5 digits long.
16 Coding on the PEF - ICD codes There is a box for a primary (P) ICD and a secondary (S) if needed.For example...a 4 y/o established patient, receives preventive exam by a nurse (V202-) and also receives vaccines (V069-).This would be coded on the preventive side of the PEFV202-√V069-
17 ICD Codes In Health Department Sites ICD codes are revised annually and are effective on October 1 of each year.ICD9 is changing to ICD10 effective October 1, 2013.Many LHDs create their own listing of most commonly used ICD codes.REMEMBER: These lists must be updated annually.
19 New & Established Patients The Patient Encounter Form (PEF or CH-45) distinguishes between New Patients and Established Patients:New Patients visits are coded in the areas highlighted in PINK.Established Patients visits are coded in the areas highlighted in BLUE.19
20 New & Established Patients NEW PATIENT - a patient who has not received a profession service (i.e., preventive, problem focused, or procedure) at any health department or satellite clinic in the COUNTY within the past three years.Determination of new or established status is made on a COUNTY basis, not a district basis.
21 New & Established Patients The PSRS (Patient Services Reporting System) determines whether the patient is new or established at computer registration when the PEF label is created.The computerized registration process is generally not done at the satellite site itself, often making it difficult for the provider to know whether the patient is new or established.
22 New & Established Patients If the provider cannot determine whether the patient is new or established by looking at the medical record, the provider should check the appropriate new patient level of visit and the appropriate established patient level of visit on the PEF. (See example on next slide.)This will save time for the provider and for staff doing the data entry. The PEF will not need to be sent back to the nurse for determination of level of visit.
23 New & Established Patients Clinic Setting: If the system is down or off-site Patient presents to nurse requesting pregnancy test:Staff doing data entry should look at label to determine if it is a new patient or established, then...Enter correct office visitMark through other visitV7241√√
24 New & Established Patients School Setting: Patient presents to nurse with headache...Staff doing data entry should look at label to determine if it is a new patient or established, then...Enter correct office visitMark through other visit7840-√√
25 New & Established Patients Under NO circumstances should staff entering data change the level of visit to accommodate a new or established patient (unless that level was also marked on the PEF, as discussed in the previous slides).The provider must determine the level of visit.
27 Coding of Preventive Visits Preventive visits are reported when the patient receives a full preventive physical exam per the guidelines in the Public Health Practice Reference (PHPR).Coding of these visits require three components:New or established patient statusAge of patientCompletion of physical exam by protocols which are listed in the PHPR
28 Refresher on Existing Code 82270 – Hemocult (fecal occult blood)qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening(i.e., pt was provided 3 cards or single triple card for consecutive collectionThe description of this code includes all three cards, therefore it would only be coded one unit for this test. Pt has to bring back at least one to three cards to be able to code
29 Components for coding “Other than Preventive E/M Visits” Commonly Referred to as “Problem Visits” in Health Department Settings
30 Components of Problem Visits Problem Visits are made up of three components which are directly linked to the coding of these services.History-consists of a combination of three parts:History of present illnessReview of systemsPast, family and social historyExamDecision makingThese three components are the driving forces behind the coding of Problem Visits.Understanding these three components is extremely important in accurate coding of problem visits.
31 History Subjective – documentation that is reported by the patient. Comparable to the “S” (subjective) portion of the SOAP noteCombination of three components –History of present illness – what the patient reports as problems, symptoms, time frames, etc.Review of systems – what body systems are affected by the presenting problemsPast, family and social history – what past, familial or social influences there might be on the seriousness and resolution of the problem
32 Exam Objective – what the provider notes when assessing the patient The exam is comparable to the “O” (objective) portion of the SOAP noteThe exam portion will be discussed in detail in the Coding of Problem Visits - New Patients section of this presentation
33 Decision MakingThe decision making component consists of three parts...Presenting problem management optionsComparable to the “A” (assessment) portion of a SOAP note.After looking at the patient history and performing exam as needed, the assessment of what the patient’s problem(s) are
34 Decision Making Diagnostic procedures ordered Provider must decide what, if any, diagnostic procedures should be doneManagement options selectedWhat treatment the patient should receiveThe last two parts combined are comparable to the “P” (plan) portion of a SOAP note
36 Coding of Problem Visits – New PatientsAmerican Medical Association (AMA) rules require that you have documented some of each of these components for new patients:HistoryExamDecision makingThe AMA rules state that you must code Other E/M Office Visits for new patients to the lowest of these three components. By lowest of these three components, they mean the component which has the least impact on the visit.Should you be missing one of the three components on a new patient, an code will have to be used.This code gives you no reimbursement and no Work Resource Based Relative Values. So the time spent with this patient will be as though it never happened.
37 Coding of Problem Visits – New PatientsThe exam component will be the lowest of the three components 99% of the time.New patients should be coded by the amount of exam performed (which are commonly referred to as “exam bullets” because this is how they are identified in CPT classification).
38 Exam – New Patients The five most common bullets are: General Appearance/Nutritional Status. (Although these appear on two lines of the HP/CH-13 and HP/CH-14 exam forms, they only count as one bullet.)Mood and AffectOrientationSkin (2 bullets possible)Inspection – looking (e.g. pink, tan, intact)Palpation - touching (e.g. warm, dry)Vital signs can be used as an exam bullet also, but three vital signs from the following list MUST be done for it to count as a bullet:Sitting or standing blood pressureSupine blood pressureHeightWeightTemperaturePulseRespiration
39 Exam – New PatientsA complete list of exam bullets can be found in the 1997 Documentation Guidelines for Evaluation & Management Services (developed jointly by the AMA & HCFA).
40 Coding of Problem Visits – New PatientsFollowing is a list of the number of exam bullets that corresponds to the level of office visit to code for new patients:1 to 5 exam bullets = or W9201 Brief6 to 11 exam bullets = or W9202 Expanded12 to 17 exam bullets = or W9203 Detailed18 to 23 exam bullets = or W9204 ComprehensiveA comprehensive office visit has the same requirements as full preventive visit (per the preventive guidelines in the PHPR). If this level of exam is performed, the provider should look at coding a full preventive exam on the patient.24 or more bullets = or W9205 ComplexComprehensive and Complex levels of new patient visits should seldom occur in a health department site. These have been addressed here in case of rare emergencies.
41 Coding of Problem Visits – New Patients The AMA expects medical providers to do a more thorough exam, within reason, on a new patient to provide a good base line for future visits (see 907 KAR 3:130).
42 Coding of Problem Visits – New PatientsRemember to have some History, some decision making, however the Coding for new patients is directly related to the amount of exam bullets performed, as it’s usually the lowest component in HD.Count the number of exam bullets and code accordingly.
44 Coding of Problem Visits – Established Patients To code a Problem Visit for an established patient, the AMA requires that only two of the three components be documented.HistoryExamDecision makingThe visit should be coded by the lowest of the two components.
45 Coding of Problem Visits – Established Patients The level of visit chosen for established patients will be driven by the lowest of either the history component or the medical decision making component.Exam performed should be what is required by protocol and medically necessary.
46 Coding of Problem Visits – Established Patients (Clinic) 99211 and W9211 BriefNo history is takenDecision making is minimalNo ROS (review of systems)Examples:Negative TB skin test reading(NEVER write a SOAP note for a negative TB skin test reading. That raises the level of visit and is never medically necessary.)
47 Coding of Problem Visits – Established Patients (School) 99211 and W9211 BriefNo history is takenDecision making is minimalNo ROS (review of systems)Examples:Daily Rx or OTC medication administration to patients who have:One stable chronic illness well controlled (minimal risk)i.e. Ritalin, Tegretol, SingulairOne previously diagnosed acute uncomplicated illness or injury (minimal risk)i.e. amoxicilin, eye drops
48 Coding of Problem Visits – Established Patients (Clinic) 99212 or W9212 LimitedRequires at least 2 of these 3 key components;Problem specific history;Straight forward decision making;ROSPatients who have one or more self-limited or minor problem(s)ExamplesSupply Visit (no complaints or problems)STD Visit (no problems or negative results)Head lice (either suspected or found)
49 Coding of Problem Visits – Established Patients (School) 99212 or W9212 LimitedRequires at least 2 of these 3 key components;Problem specific history;Straight forward decision making;ROSPatients who have one or more self-limited or minor problem(s)ExamplesHeadacheUpset stomachHead lice (either suspected or found)EaracheMenstrual crampsDaily Rx or OTC medication administration with a complaint/problem i.e.: Ritalin, Singulair, amoxicilin
50 Coding of Problem Visits – Established Patients (Clinic) 99213 or W9213 ExpandedRequires at least 2 of these 3 key components;Expanded problem focused history;Expanded problem focused examination;Decision making of low to moderate complexityExamplesPt to receive depo – wt gain 5 lb since last visit, c/o occasional headaches – counseled & depo adm.Positive TB skin test readingPositive STD visit with treatmentDaily Rx medication administration to patients who have one stable chronic illness w/o problems (i.e. DOT – Communicable Disease)
51 Coding of Problem Visits – Established Patients (School) 99213 or W9213 ExpandedRequires at least 2 of these 3 key components;Expanded problem focused history;Expanded problem focused examination;Decision making of low to moderate complexityExamplesDaily Rx medication administration to patients who have one stable chronic illness (i.e.: insulin)Injuries that require the patient to go homeMedication unavailable and coordination of care with parent or physician is necessary
52 Coding of Problem Visits – Established Patients (Clinic) 99214 or W9214 DetailedRequires at least 2 of these 3 key components;Detailed history;Detailed examination;Decision making of moderate complexityPresenting problems are of moderate to high complexityExamplesTrue contraindication to contraceptive methodsOCs - B/P 160/92, c/o severe HA’s daily with visual impairment - no contraceptive given until patient is further evaluatedPatients presenting with problems significant enough that more case management is necessaryPt with abnormal breast exam*******Please keep in mind: 907 KAR 3:010 Section 4PHYSICIAN’S MEDICAID only pays Doctors for TWO visits per 12 months
53 Coding of Problem Visits – Established Patients (School) 99214 or W9214 DetailedRequires at least 2 of these 3 key components;Detailed history;Detailed examination;Decision making of moderate complexityPresenting problems are of moderate to high complexityExamplesPatients who experience exacerbation of chronic illnesses (i.e.: diabetes, asthma, ADHD, epilepsy)Patients who present with acute uncomplicated problems requiring more care coordination (i.e.: broken bones, emergency room, stitches, adverse reactions)*******Please keep in mind: 907 KAR 3:010 Section 4PHYSICIAN’S MEDICAID only pays Doctors for TWO visits per 12 months
54 Coding of Problem Visits – Established Patients (Clinic) 99215 or W9215 ComprehensiveRequires at least 2 of these 3 key components:Comprehensive history;Comprehensive examination;Decision making of high complexityPresenting problems are of moderate to high complexitySignificant risk to the life of the patientExamplesHIVRapeAbrupt neurological changesAnaphylactic reaction to vaccineEmergency treatment necessary via EMS*******Please keep in mind: 907 KAR 3:010 Section 4PHYSICIAN’S MEDICAID only pays Doctors for TWO visits per 12 months
55 Coding of Problem Visits – Established Patients (School) 99215 or W9215 ComprehensiveRequires at least 2 of these 3 key components:Comprehensive history;Comprehensive examination;Decision making of high complexityPresenting problems are of moderate to high complexitySignificant risk to the life of the patientExamplesSevere or prolonged seizuresDiabetic comaHead injuries with prolonged unconsciousness or abrupt neurological changesEmergency treatment necessary via EMS*******Please keep in mind: 907 KAR 3:010 Section 4PHYSICIAN’S MEDICAID only pays Doctors for TWO visits per 12 months
56 Multiple Visits for the Same Patient on the Same Day
57 OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL Multiple Visits for the Same Patient on the Same Day with Different Problem (Clinic)A 25 modifier may be reported with a Preventive visit, if there is a significant enough and separately identifiable problem . The 25 modifier would be listed with problem-focused E/M visit.When immunizations are given, problem-focused E/M with a 25 modifier may be reported if there is a distinct and separately, identifiable reason for the E/M visit (i.e., a different diagnosis code).When an E/M is reported on the same day as another procedure , such as a MNT; the E/M will require a 25 modifier and the diagnosis code for the E/M needs to different from the diagnosis code for the MNT.OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVELCPT NEW Visit TypeCPT EST. Visit TypePROVIDER99201 Brief99211 Brief99202 Expanded99212 Limited99203 Detailed99213 Expanded99204 Comprehensive99214 DetailedICD (P)99205 Complex99215 Comprehensive25 MODIFIER Separate E/M by same provider/same dayNURSEICD (S)W9201 BriefW9211 BriefW9202 ExpandedW9212 LimitedW9203 DetailedW9213 ExpandedREF/DISPW9204 ComprehensiveW9214 DetailedW9205 ComplexW9215 ComprehensiveThe 25 modifier is located beneath the Other Then Preventive codes section.You may either check or circle the 25.
58 Example of when to use the 25 Modifier: 39 year old established pt comes in for Family Planning preventive visit, while doing this pt’s family planning preventive visit, the APRN finds vaginal warts, and with the permission of the pt, treats. Coding would consist of:
59 Another Example of when to use the 25 Modifier: 17 year old established pt comes in for family planning supplies and RN finds out she has not received the Gardasil vaccine. Pt wants to receive this vaccine and is counseled per component. Coding would consist of: unit 90649
60 Multiple Visits for the Same Patient on the Same Day with Different or Same Problem (School) If a patient presents to the local health department satellite school site more than one time on the same day for a different or same problem, only one Office Visit (OV) can be billed – per MedicaidHowever, each visit must be documented in the patient’s medical recordIf a patient is seen multiple times for the different or same problem on the same day; following the last visit of the day, the nurse should review the documentation and select the most complex visit and submit that PEF for the appropriate level of billing
61 Guiding PrinciplesOnly provide the level of care that is medically necessary.Always provide and document services in accordance with the Public Health Practice Reference and with established best practices.Always code and document exactly what care was provided.
62 References: Current Procedural Terminology 2011 International Classification of Disease 9th Revision 20111995 CMS document: Documentation Guidelines to Evaluation & Management Services1997 CMS document: Documentation Guidelines to Evaluation & Management ServicesCMS Evaluation & Management Service Guide