Presentation on theme: "ICD-9, CPT, E&M Coding Documentation and Compliance"— Presentation transcript:
1 ICD-9, CPT, E&M Coding Documentation and Compliance …or the in-service for thein-service!!
2 …You’ve just seen a patient in your office… …and after the examYou want to get paid(After all, you need to pay mortgage, food, etc)Insurance will pay you if…You tell the company what you did…AND…You tell the company why you did it
3 Types of “Codes” Procedure codes ICD What I did during the visitTwo TypesCPTEvaluation and ManagementICDWhy I did itThe actual diagnosis code…and these must make sense together
5 ICD CodesICD = International Statistical Classification of Diseases and Related Health ProblemsProvides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease.Every health condition can be assigned to a unique category and given a code, up to six characters long.Easy to understandAllows for global (international) understanding of information
6 ICD-9 (9th version- currently one in use) : Infectious and parasitic diseases: Neoplasms: Endocrine, nutritional, metabolic and immunity disorders: Blood ad blood-forming organs: Mental disorders (used by primary care and psych for research. DSM codes are used for clinical billing by psych): Nervous system: Sense organs: Circulatory system: Respiratory system: Digestive system: Genitourinary system: Complications of pregnancy/childbirth: Skin and subcutaneous tissues: Musculoskeletal system and connective tissue: Congenital anomalies: Certain conditions originating in the perinatal period: Symptoms, signs and ill-defined conditions: Injury and poisoningE and V codes: External causes of injury and supplemental classification
7 ICD-9 Can list by disease or symptom Get better reimbursement for more detailSome insurances will only pay for a certain number of visits per diagnosise.g., diabetesLarge book with diagnostic codes or can get on line
8 More detail the better…. Break these down further! ICD-9 codesMore detail the better….Break these down further!
10 Endocrine, nutritional and metabolic diseases, and immunity disorders (240-279) diseases of other endocrine glands ( )Note: for , the following fifth digit can be added:(250.x0) Diabetes mellitus type 2(250.x1) Diabetes mellitus type 1(250.x2) Diabetes mellitus type 2, uncontrolled(250.x3) Diabetes mellitus type 1, uncontrolled(250) Diabetes mellitus(250.0) Diabetes mellitus without mention of complication(250.1) Diabetes with ketoacidosis(250.2) Diabetes with hyperosmolarity(250.3) Diabetes with other coma(250.4) Diabetes with renal manifestations(250.5) Diabetes with ophthalmic manifestations(250.6) Diabetes with neurological manifestations(250.7) Diabetes with peripheral circulatory disorder(250.8) Diabetes with other nonspecified manifestations(250.9) Diabetes with unspecified complication
11 780-799: Symptoms, signs and ill-defined conditions (780) General symptoms(780.0) Alteration of consciousness(780.01) Coma, nondiabetic, nonhepatic(780.02) Mental status changes(780.09) Semicoma, stupor(780.1) Hallucinations(780.2) Syncope(780.3) Convulsions(780.31) Seizures, convulsions, febrile(780.39) Seizures, convulsions, other(780.4) Dizziness/vertigo, NOS(780.5) Sleep disturbance, unspec.(780.53) Hypersomnia, sleep apnea(780.53) Sleep apnea w/ hypersomnia(780.58) Movement disorder, sleep related(780.6) Fever, nonperinatal(780.7) Malaise and fatigue(780.8) Sweating, excessive(780.9) Other general symptoms(780.92) Crying, infant, excessive(780.93) Memory loss(780.94) Early satiety
12 Current Procedural Terminology CPTCurrent Procedural Terminology
13 CPT CPT = Current Procedural Terminology Code Set accurately describes medical, surgical, and diagnostic servicesDesigned to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.The current version is the CPT 2008.
14 CPTA CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. There are approximately 7,800 CPT codes ranging from through Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure.
15 Current Procedural Terminology Chapter 1: Evaluation and Management Codes ( )Chapter 2: Anesthesia Codes ( )Chapter 3: Surgery Codes ( )Chapter 4: Radiology Codes ( )Chapter 5: Pathology/Laboratory Codes ( )Chapter 6: Medicine Codes ( )Appendices: Modifiers, Deleted codes
16 V codes: Supplemental classification V01 Contact with or exposure to communicable diseasesV02 Carrier or suspected carrier of infectious diseasesV09 Infection with drug-resistant microorganismsV10 Personal history of malignant neoplasm (i.e. cancer)V16 Family history of malignant neoplasmV17 Family history of certain chronic disabling diseasesV20 Health supervision of infant or childV21 Constitutional states in developmentV22 Normal pregnancy
17 V codes, cont V23 Supervision of high-risk pregnancy V24 Postpartum care and examinationV25 Encounter for contraceptive managementV28 Encounter for [antenatal] screening of motherV29 Observation and evaluation of newborns for suspected conditions not foundV30 Single livebornV31 Twin birth mate livebornV48 Problems with head neck and trunkV49 Other conditions influencing health statusV50 Elective surgery for purposes other than remedying health statesV51 Aftercare involving the use of plastic surgery
18 V codes, cont V56 Encounter for dialysis and dialysis catheter care V57 Care involving use of rehabilitation proceduresV58 Encounter for other and unspecified procedures and aftercareV60 Housing, household and economic circumstancesV64 Persons encountering health services for specific procedures not carried outV65 Other persons seeking consultationV66 Convalescence and palliative careV67 Follow-up examinationV68 Encounters for administrative purposesV69 Problems related to lifestyleV70 General medical examinationV71 Observation and evaluation for suspected conditions not foundV80 Special screening for neurological eye and ear diseasesV81 Special screening for cardiovascular respiratory and genitourinary diseasesV85 Body mass index
19 Relationship between CPT and ICD-9 The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD , closed fracture of a phalanges of the foot. Such a claim would be quickly identified and rejected.
20 …trivia for boards… Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS)Diagnosis Codes ICD – 9Creates medical necessityLevel I CPTUpdated AnnuallyLevel II (national) HCPCS (A-V)Alphanumeric SystemLevel III (State) Local Codes (W-Z)
21 Evaluation and Management Most confusing for physicians E & M CodingEvaluation and ManagementMost confusing for physicians
22 What are E&M Codes?The Evaluation & Management (E&M) codes are a sub-set of the CPT codes.Can be used by all privileged providersDescribes:Complexity of care provided to a patient for non-procedural visits.The place of service (inpatient or outpatient)The type of service (new vs. established, consult, preventive, ER, critical care, etc)Defined by 3 componentsThe patient historyThe physical examinationMedical decision making
23 Why Code? REIMBURSEMENT Over coding = Fraud Third Party Payers/Insurance AgenciesProspective Payment Systems (PPS)Over coding = FraudUnder coding = Lost Revenue
24 What Do Coders Look For?Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing informationIt is the Content, not the volume, of documentation that determines your E&M code!
25 What Do Coders Look For?Every patient encounter should be legible and include:Date of EncounterReason for the visit (chief complaint)Appropriate history of present illnessAn exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent)Review of lab, x-ray, other ancillary services when appropriateAssessmentPlan of care/Treatment optionsProvider signature
26 Why is Documentation Important? The documentation must support the E&M code you select.Your documentation must also support the medical necessity of the services provided.The first step is to clearly document the reason for every visit – the chief complaint.The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity.However it is acceptable to document “Follow-up for _____”.“If it isn’t documented, it wasn’t done!”
27 New vs. Established Consult Inpatient vs. Outpatient Patient TypeNew vs. EstablishedConsultInpatient vs. Outpatient
28 New vs. Established New patient Any patient who has not received professional services, within the previous 36 months, from a provider within the same group, of the same specialtySame group practice: One Federal Tax ID number for all providers, if more than one Federal Tax ID, can consider the patient newe.g., current practice seen in OLBH ER and Outreach officesProfessional Services: Phone call, prescription, hospital or office visit, etc.Specialty Issue: Optional if one federal Tax ID is shared by practitioners of other specialties (e.g., surgeon and FP)** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO
29 Average and Recommended Code Distributions The difference in the bell curves represents loss in physician income!!
30 Determining the Correct E&M Code There are three key components to consider when selecting the appropriate E&M:HistoryExamMedical Decision Making (MDM)All three components must be documented for a new patient (new to clinic or not seen within the past three years). Indicate in CC if patient is new.Only two of the three components must be documented for established patients (seen within the past three years).E&M selection should never be based on the allotted time on the appointment schedule!
31 Determining the Correct E&M Code To determine the correct level E&M code, consider the complexity of your patient’s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam.Remember:For a new clinic patient, initial consult, initial inpatient visit or ED encounter you must document all three key componentshistory, exam and your medical decision making.
32 Defining Levels of E&M Services 7 componentsHistoryExaminationMedical Decision MakingCounselingCoordination of careNature of Presenting ProblemTime
34 HistoryAlso has several components to determine “complexity” or “type”History of Present Illness (HPI)Review of Systems (ROS)Past Family and/or Social History (PFSH)The extent of history is dependent on clinical judgment and the nature of the presenting problem.The four types of History include: Problem focused, Expanded Problem Focused, Detailed and Comprehensive.
36 History – Chief Complaint Chief Complaint Requiredconcise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.The CC is usually stated in the patient’s own words.For example, patient complains of upset stomach, aching joints, and fatigueCannot be the words “follow up” alone
37 History – History of Present Illness Two types of HPIBrief, which includes documentation of one to three HPI elements.In the following example, three HPI elements – location, severity, and duration – are documented:CC: A patient seen in the office complains of left ear pain.Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.
38 History – History of Present Illness Extended, which includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions.In the following example, five HPI elements – location, severity, duration, context, and modifying factors – are documented:Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.
39 History Components Location Quality Severity Duration Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referredQualitySpecific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worseningLaceration as jagged or straightSore throat as scratchySeverityPain scale, “compared to”, observation by physician (discomfort, wincing)Duration
40 History Components Timing Context Modifying factors Onset of problem or symptom and progression, recurrent, comes and goes, worsens or improvesContextAssociated with activity, improves with activity, etcModifying factorsSteps the patient has taken to alleviate symptoms, what exacerbates symptoms, is helped by, is hindered byAssociated signs/symptomsClinical impressions direct physician questioningSpecific symptoms (weakness, headache with injury)Generalized symptoms, chills, fever, “pertinent positives and negatives”
41 History Guidelines HPI must be documented by the physician ROS and/or PFSH can be recorded by ancillary staffPhysician must supplement or confirm the informationIf obtained at a prior visit, do not need to re-record. Can review and updateDescribe new informationNote date and location of earlier information
42 History Guidelines If unable to obtain a history Describe patient’s medical condition or circumstance which precludes obtaining a history
44 Review of Systems Definition The following “systems” are recognized: An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experiencedThe following “systems” are recognized:Constitutional (fever, weight loss) - PsychiatricEyes EndocrineEars, nose, mouth throat - NeurologicalCardiovascular - Allergic/ImmunologicRespiratoryGastrointestinalMusculoskeletalIntegumentary (skin and/or breast)Hematologic/Lymphatic
45 Review of Systems Three categories of review Problem Pertinent ROS inquires about the system directly related to the problem(s) identified in the HPIBoth positive responses and pertinent negatives should be documentedIn the following example, one system – the ear – is reviewed:CC: Earache.ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.
46 Review of Systems Extended ROS inquires about the system directly related to HPI AND a limited number of additional systems2-9 systems which are documentedIn the following example, two systems – cardiovascular and respiratory – are reviewed:CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.”ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.
47 Review of Systems Complete ROS inquires about the system directly related to the HPI AND all other body systemsAt least 10 body systems must be documentedThose systems w/pertinent +or- responses must be individually documented, however for the remaining systems, “all other systems are negative” is permissible
48 Review of SystemsIn the following example, 10 signs and symptoms are reviewed:CC: Patient complains of “fainting spell.”ROS:Constitutional: weight stable, + fatigue.Eyes: + loss of peripheral vision.Ear, Nose, Mouth, Throat: no complaints.Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.Respiratory: + shortness of breath on exertion.Gastrointestinal: appetite good, denies heartburn and indigestion.+ episodes of nausea. Bowel movement daily; denies constipation or loose stools.Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.Skin: + clammy, moist skin.Neurological: + fainting; denies numbness, tingling, and tremors.Psychiatric: denies memory loss or depression. Mood pleasant.
50 History - PFSH Past History Family History Social History Past experience with illnesses, operations, injuries and treatmentsFamily HistoryReview of medical events in patients family, including hereditary diseaseSocial HistoryAge appropriate review of past and current activities
51 History - PFSH Pertinent review of the history areas directly related to the problem(s) identified in the HPI.Must document one item from any of the three history areas.In the following example, the patient’s past surgical history is reviewed as it relates to the current HPI:Patient returns to office for follow up of coronary artery bypass graft in Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.
52 History - PFSH Complete A review of two or all three of the areas, depending on the category of E/M service.Requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.A review of two history areas is sufficient for other services.
53 History - PFSHAt least one specific item from each of the history areas must be documented for the following categories of E/M services:Office or other outpatient services, new patient;Hospital observation services;Hospital inpatient services, initial care;Consultations;Comprehensive Nursing Facility assessments;Domiciliary care, new patient; andHome care, new patient.
54 History - PFSH Does NOT need to be re-recorded Record new information only“No change” PFSH can be documented
55 History Algorithm History Type HPI ROS PFSH Problem Focused (1 point) BriefNoneExpanded Problem Focused (2 points)Problem pertinentDetailed (3 points)ExtendedPertinentComprehensive (4 points)Complete
57 Physical ExamLooked at either byBody AreasOrgan Systems
58 Physical Exam Body areas recognized: Head (including face) Neck Chest, including breast and axillaeAbdomenGenitalia, groin, buttocksBack (including spine)Each extremity (separately)
59 Physical Exam Organ systems recognized ConstitutionalEyesENT, MouthCardiovascularRespiratoryGIGUMusculoskeletalSkinNeurologicPsychiatricHematologic; Lymphatic; ImmunologicThe general multi-system exam should include findings of at least 8 of the above 12 organ systems
60 Documentation of Examination Make sure you note specific abnormal or relevant findings of affected body areas or organ systemsBrief statement indicating negative or normal is sufficient for unaffected or asymptomatic systemsDescribe abnormal or unexpected findings of asymptomatic areas or organs
61 > 6 Bulleted Elements Physical ExaminationTypeEither thisOr thisProblem Focused (1 point)< 1 organ system/Body area1-5 bulleted elementsExpanded Problem Focused (2 points)2-4 Organ Systems/Body areas> 6 Bulleted ElementsDetailed Exam (3 points)5-7 Organ Systems/Body Areas> 2 bulleted elements from 6 areas or> 12 bullets from > 2 areasComprehensive Exam (4 points)> 8 organ systems/body areasComplete single system examination or> 2 bulleted elements from 9 areas
62 Physical Examination Type of Examination Description Problem Focused A limited examination of the affected body area or organ system.Expanded Problem FocusedA limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).DetailedAn extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s).ComprehensiveA general multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).
63 Physical Examination General Multi-System Examinations TYPE OF EXAMINATIONDESCRIPTIONProblem FocusedInclude performance and documentation of elements identified by a bullet in 1 or more organ system(s) or body area(s)Expanded Problem FocusedInclude performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).
64 Physical Examination General Multi-System Examinations TYPE OF EXAMDESCRIPTIONDetailedInclude at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.Comp.1997 Documentation Guidelines for Evaluation and Management Services: Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected.1995 Documentation Guidelines for Evaluation and Management Services: Eight organ systems must be examined. If body areas are examined and counted, they must be over and above the 8 organ systems.
65 Exam Bullets Constitutional Eyes Ears, Nose, Mouth and Throat 3 vital signsGeneral appearanceEyesInspection of Conjunctiva and LidsExamination of Pupils and Iris (PERLA)Ophthalmoscopic discs and posterior segmentsEars, Nose, Mouth and ThroatExternal appearance of Nose and EarsOtoscopic ExaminationAssessment of HearingInspection of Nasal Mucosa/SeptumExamination of oropharynx
66 Exam Bullets Neck Respiratory Examination of Neck Examination of ThyroidRespiratoryAssessment of respiratory effortPercussion of ChestPalpation of ChestAuscultation of Lungs
67 Exam Bullets Cardiovascular Chest (breasts) Palpation of PMI Auscultation of the HeartAssessment of Lower Extremity EdemaExamination of Carotid ArteryExamination of abdominal aortaExamination of femoral pulseExamination of pedal pulseChest (breasts)Inspection of breastsPalpation of breasts and axillae
68 Exam Bullets Gastrointestinal (abdomen) Genitourinary (male) Examination with notation of masses or tendernessExamination of liver and spleenExamination for presence/absence of herniasExamination of anus, perineum, rectum, including sphincter tone, hemorrhoidsObtain stool for occult bloodGenitourinary (male)Examination of scrotal contentsExamination of PenisDRE prostate
69 Exam Bullets Genitourinary (female) Lymphatic Examination of external genetaliaExamination of urethraExamination of bladderExamination of cervixExamination of uterusExamination of adenexaLymphaticPalpation of lymph nodes in two or more areasNeck, axillae, groin, other
70 Exam Bullets Musculoskeletal Examination of gait and station Examination of joints, bones and muscles of one or more of the following 6 areasHead and NeckSpine, ribs and PelvisRight Upper ExtremityLeft Upper ExtremityRight Lower ExtremityLeft Lower ExtremityExamination includes…Inspection and/or palpation with notation of any misalignment, asymmetry, crepitation, etc; range of motion with notation of pain, crepitation; assessment of stability; assessment of muscle strength
71 Exam Bullets Skin Neurologic Psychiatric Examination of skin and subcutaneous tissuePalpation of skin and subcutaneous tissueNeurologicTest cranial nerves with notation of deficitExamination of DTRExamination of sensationPsychiatricDescription of judgment and insightBrief assessment of mental status
73 Determination of Medical Decision Making Based uponNumber of diagnoses or management optionsAmount and complexity of dataOverall risk
74 Medical Decision Making (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option.Measured by documentation of the following:Number of diagnoses and/or management options that must be considered.Amount and/or complexity of data to be reviewed.Risk of complications, morbidity and/or mortality, and co-morbidities.Four typesStraightforward, Low Complexity, Moderate Complexity, and High Complexity.
75 Documentation to Support Complexity Consider the following for riskChronic illness(es)Well controlledMild exacerbationSevere exacerbationAcute illnessUncomplicated like allergic rhinitisWith systemic symptoms like pneumonitis
76 Medical Decision Making Diagnoses/Management Options Max of 4 points Problem CategoriesNumber of ProblemsPossible PointsScoreSelf Limited/minorMax of 21Established Problem – stable or improvingEstablished problem – worsening2New problem (no further work up)Max of 13New problem (work up needed)4
77 Documentation to Support Complexity Consider the following…Did you order/review labs?Did you order/review X-rays, US, MRIDid you order/review any other testingDid you visualize image, tracing, or specimenDid you review or summarize old recordsMust document this on the record…old records reviewed which noted ….
78 Medical Decision Making Amount and Complexity of Data Max of 4 points Type of DataCheck if DonePossible PointsScoreReview/Order tests (8xxxx clinical)1Review/order tests (7xxxx radiology)Review/order tests (9xxxx medicine)Discuss test results with performing physician2Independent review of tracing, specimen, imageDecision to obtain medical recordsReview, summarize old records and/or obtain history
79 Table of Risk Level of risk Presenting problem(s) Diagnostics ordered Management optionsMinimal (1 point)One self-limited/minor problem (e.g., URI)Lab tests requiring venipunctureCXREKGUrinalysisRestGarglesAce wrapLow (2 points)2+self limited/minor problems1 stable/chronic illnessAcute uncomplicated illness/injuryPhysiologic tests not under stress (pulm. Function)Non-cardiac imaging w/bariumLab requiring arterial punctureSkin biopsyOver the counter drugsMinor surgery w/no identified riskPT/OTIV fluids w/o additivesModerate (3 points)1+chronic illnesses with mild progression, or side effects of treatment2+ stable chronic illnessesUndiagnosed new problem w/uncertain prognosisAcute illness with systematic symptomsAcute uncomplicated injuryPhysiologic test under stressDiagnostic endoscopy w/no risk factorsDeep needle or incisional biopsyObtain fluid from body cavityMinor surgery w/risk factorsElective major surgery w/no risksPrescription drug managementIV with additivesHigh (4 points)1+ chronic illness with severe exacerbation or side effects of treatmentAcute/chronic illness that poses a threat to life/bodily functionAbrupt change in neurologic statusCardiovascular imaging w/contrast w/risk factorsCardiac electrophysiological testsDiagnostic endoscopies w/identified risk factorsElective major surgery w/risk factorsEmergency major surgeryParenteral controlled substancesDNR due to poor prognosis
80 Medical Decision Making The HIGHEST level of ANY ONE of the three aspects of a medical decision making will determine the overall level chosen
81 Medical Decision Making Final Medical Decision Making 2 of 3 rule Straight ForwardLowModerateHighDiagnosis &/or Management OptionsMinimal (1)Limited (2)Multiple (3)Extensive (> 4)Amount of Data ReviewedTable of RiskLow (2)Moderate (3)High (4)
82 Defining Levels of E&M Services 7 componentsHistoryExaminationMedical Decision MakingCounselingCoordination of careNature of Presenting ProblemTime
83 Counseling and Coordination of Care Discussion with patient or family concerning one or more of the following:Diagnostic resultsPrognosisRisk & benefits of management optionsInstruction for managementCompliance
84 Time…as another factor Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the patient and/or family encounterDocumentation requirementsTotal face to face time or encounterTotal counseling/coordination timeContent of counseling/coordination
85 Time based billing…example cc: DepressionHx cc: 59 y/o female w/depression and anxiety. Denies suicidal ideations. Hx ativan use in pastExam: vitals (list)A/P: Depression. Had long discussion w/patient and counseled him on exacerbating factors and treatment options. Rx ordered (list)Total visit time 25 minutes, counseling time 15 minutes
86 Summing Up Your Services Billing the Correct Code…
87 The Constants of Coding 3 of 3 ruleGo to the lowest componenti.e., 2,3,4 = 23,3,4 = 3Used for new patient, initial consults, initial hospital care and emergency department visits2 of 3 ruleGo to the middle component2,3,4 = 3Used for established patient, subsequent hospital f/u, f/u consult
88 New vs. Established Patient New PatientAll key components must meet or exceed the stated requirements to qualify for a particular levelEstablished PatientTwo key components must meet or exceed stated requirements to qualify for a particular level
89 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of ServiceHistoryExaminationMedical Decision Making99201Problem focusedStraight forward complexity99202Expanded problem focused99203DetailedLow complexity99204ComprehensiveModerate complexity99205High complexity
90 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of ServiceHistoryExaminationMedical Decision Making99201Problem focusedStraight forward complexity99202Expanded problem focused99203DetailedLow complexity99204ComprehensiveModerate complexity99205High complexity
91 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of ServiceHistoryExaminationMedical Decision Making99201Problem focusedStraight forward complexity99202Expanded problem focused99203DetailedLow complexity99204ComprehensiveModerate complexity99205High complexity
92 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of ServiceHistoryExaminationMedical Decision Making99201Problem focusedStraight forward complexity99202Expanded problem focused99203DetailedLow complexity99204ComprehensiveModerate complexity99205High complexity
93 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistoryPhysical ExamMedical Decision makingTime99211Nursing service onlyN/ANursing order599212Problem Focused (1)Straight forward (1)1099213Expanded Problem Focused (2)Low Complexity (2)1599214Detailed (3)Moderate Complexity2599215Comprehensive (4)High Complexity (4)40
94 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistoryPhysical ExamMedical Decision makingTime99211Nursing service onlyN/ANursing order599212Problem Focused (1)Straight forward (1)1099213Expanded Problem Focused (2)Low Complexity (2)1599214Detailed (3)Moderate Complexity (3)2599215Comprehensive (4)High Complexity (4)40
95 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistoryPhysical ExamMedical Decision makingTime99211Nursing service onlyN/ANursing order599212Problem Focused (1)Straight forward (1)1099213Expanded Problem Focused (2)Low Complexity (2)1599214Detailed (3)Moderate Complexity (3)2599215Comprehensive (4)High Complexity (4)40
96 Inpatient Codes Follow 3 of 3 rule Inpatient Services and Observation Inpatient ConsultsInpatient follow ups follow the 2 of 3 rule
97 Other Medical Services General ConsultantPre/Post Operative Consults
98 Definition of Consultation Type of service provided by a physician whose opinion ad advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.
99 Consultation Services Documentation MUST includeRequest for consultation documented in the medical recordReason for consultation (medical necessity)Report- Consultant’s opinion, advice and evaluation of the patient (this MUST be communicated back to the requesting physician)Have separate initial codingFollow up visits use established patient visits
100 Preoperative Consultation Must request opinion or advice regarding a specific problemRequest and need for consult must be documented in the medical recordAny services ordered or performed must be documentedConsultant’s opinion, advice and evaluation of the patient must be communicated back to the requesting surgeon
101 Preoperative Clearance ICD-9 diagnosis codesV72.81 Preoperative cardiovascular examinationV72.82 Preoperative op respiratory examinationV72.83 Other specified preoperative examinationV72.84 Preoperative examination, unspecifiedV72.85 Other specified examinationMust supplement with sigh/symptom/dx codesMust also include surgical indication (eg, cataracts)
102 Rules for Consultation 99241-99275 Opinion or advise regarding E&M of a specific problem is requestedDocumented request from appropriate source is required (if patient generated for )Written report sent to referring provider (a letter for an outpatient)Initiation of care at time of consult is acceptablePost-op consult by provider performing pre-op clearance should use subsequent hospital codes or established office visit codes
105 Documentation Requirements Established Patient Office Visit Level of serviceHistoryExaminationMedical decision making99211Nursing service onlyNursing order99212Problem focusedStraight forward complexity99213Expanded problem focusedLow complexity99214DetailedModerate complexity99215ComprehensiveHigh complexity
106 Example 99211 Non-physician visit Patient Calls Advice Nurse with Possible UTIPatient brings and drops-off UANurse processes UAYou (Doctor/PA/NP) review and find UTINurse calls in antibiotics and documents in ChartBlood Pressure Check
107 Example 99212 4y/o female with fever and ear pain Established Patient: 2 of 3 requiredHistory: 1-2 HPIExam: 1-5 elementsMedical Decision Making: 1 self limited minor problem
108 Example 99212 4y/o female with fever and ear pain HistoryFever 101Left ear 3 daysExamInjection with redness and drainage of tympanic membranePharynx red, no exudates+ anterior cervical nodesLungs clearHeart rrrMedical Decision MakingOM – Prescription AntibioticsFever controlRecheck in 2 weeks
109 Example 99213 4 y/o female with fever and ear pain History:1-3 HPI elements …ANDROSExam: 6-11 elementsMedical Decision Making:2 self-limited or minor problems …OR1 new problem plus low risk
110 Example 99213 4 y/o female with fever and ear pain History:Fever and Ear pain for 3 daysROSCough/sinus congestion, sore throat, vomiting and diarrheaPFSHNKA/Immunization/passive smoking/any chronic medsExam3 vitals (weight, temp, BP)Left TM red, pharynx red, tender nodes, neck supple, lungs clear, heart regular, abdomen non-tenderMedical Decision Making:LOMAntibiotics/Fever ControlRecheck in 2 weeksCall if worse
111 Example 99214 58 y/o male at 3 month check up Detailed historyExtended HPIExtended ROSOne element PFSHDetailed exam12 exam elements from at least 2 systemsModerate Complexity2 of the following: Multiple dx; Moderate amount and complexity of data; Moderate risk
112 Example 99214 58 y/o male at 3 month check up HistoryHTN; DM; DJD; vision exam UTD; (-) HA; (-) SOB; (-) CP; (-) NVDC; (-) Hematochezia; (-) NocturiaPFSHUnchanged from prior examDetailed exam12 exam elements from at least 2 systemsMedical Decision MakingEKG, Pulse Oximetry; UA, Rapid StrepReview of CXRPrescriptions writtenDocument ProceduresDocument OMM
116 Other Billable Services Injections/ImmunizationsSmoking CessationVisit and procedures
117 Injections/Immunizations 90471 is for first administration90472 is for EACH additional administrationCannot report if patient brings their own supplyCannot bill (nursing service) if only injection givenMust provide separately identifiable servicee.g., get vital signs
118 Smoking Cessation Document that you told patient to stop smoking 99406 Greater than 3 minutes, up to 10 minutes99407 Greater than 10 minutes
119 Other Billable Services Digital Rectal Exam for Prostate Cancer ScreeningG0102Visual Acuity Exam (Snellen Chart)99173Needle Sticks!!96150 – e.g., when an occupational health nurse sees a patient due to a needle stick he/she can code this encounter as E/M and CPT with the applicable ICD-9 primary for the wound and a secondary ICD-9 code of the External cause.
120 Billing an office Visit and a Procedure Procedure must be a separate service from the evaluation and management serviceModifier 25 should be added to the evaluation and management service to identify that it is a separate service
121 Other Coding Opportunities Modifiers22 Unusual procedural service25 significantly, separately identifiable E&M service by the same physician on the same day of the procedure or other servicee.g., patient comes in with sinus infection – you do OMT “cause it will help” vs. patient coming in specifically for OMT32 Mandated by 3rd party (HMO)51 Multiple Procedures
123 Other…If you see a patient and admit directly to a hospital, you should submit only the hospital code.
124 Critical Care Codes Use appropriate E&M code if < 30 minutes 99291 First minutes of evaluation and management99292Each additional 30 minutes (can round up after 15 minutes)e.g., minutes = x 1 and x 2
125 Prolonged Care CodesThreshold time is 30 minutes over the time component allotted for the E&M codeOutpatientFace to face timeInpatientInpatient or outpatient office/floor/unit time without direct patient contacte.g., IV running for rehydration in your office for 1 hour
126 Other Coding Opportunities 99050After Hours99052Services Provided between 11pm and 8am99054Sundays/Holidays99024Post op follow up in Global Period99058Office services on Emergent basis99082Unusual Travel (transport/escort)99090Analysis of Data Stored on Computer
127 For Further Information Evaluation and Management Services Guide - AMA