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CPT & ICD-9 CODING Debra Dockter NP-BC. Objective of Coding Provider Provider - To prepare a standardized “bill” for services - To prepare a standardized.

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Presentation on theme: "CPT & ICD-9 CODING Debra Dockter NP-BC. Objective of Coding Provider Provider - To prepare a standardized “bill” for services - To prepare a standardized."— Presentation transcript:

1 CPT & ICD-9 CODING Debra Dockter NP-BC

2 Objective of Coding Provider Provider - To prepare a standardized “bill” for services - To prepare a standardized “bill” for services given to a patient. given to a patient. Payer Payer - To determine the amount to be paid to the - To determine the amount to be paid to the provider. provider.

3 Definition CPT (current procedural terminology) Codes - CPT (current procedural terminology) Codes - are numbers assigned to every task & service a medical practitioner may provide to a patient. are numbers assigned to every task & service a medical practitioner may provide to a patient. includes: medical includes: medical surgical surgical diagnostic services diagnostic services *Used by insurers to determine the amount of reimbursement a practitioner will receive from the insurance company. *Used by insurers to determine the amount of reimbursement a practitioner will receive from the insurance company.

4 CPT Codes Developed, maintained, and copyrighted by AMA (American Medical Association) Developed, maintained, and copyrighted by AMA (American Medical Association) New codes are developed for new services, New codes are developed for new services, current codes may be revised, & old unused codes are discarded annually. current codes may be revised, & old unused codes are discarded annually. *The exception: Medicare patient *The exception: Medicare patient

5 CPT Codes Examples Examples a physical exam a physical exam flu vaccination flu vaccination chicken pox vaccine (varicella) chicken pox vaccine (varicella) laceration repair laceration repair *Service reimbursement will vary according to medical provider and insurance company. *Service reimbursement will vary according to medical provider and insurance company.

6 3 Key Components for CPT Coding 3 Key Components for CPT Coding Necessary components needed for billing a patient visit : Necessary components needed for billing a patient visit : * History of problem(s) * History of problem(s) * Exam related to problem(s) * Exam related to problem(s) * Medical Decision * Medical Decision These components are determined by: These components are determined by: Evaluation & Medical Decision Making Evaluation & Medical Decision Making *Great resource: *Great resource:

7 Evaluation & Medical Decision Making The levels of E & M services are based on 4 types of examinations: The levels of E & M services are based on 4 types of examinations: Problem Focused Problem Focused Expanded Problem Focused Expanded Problem Focused Detailed Detailed Comprehensive Comprehensive

8 Patient Criteria for E/M I. Patient Type: New I. Patient Type: New No professional services in the last 3 years. No professional services in the last 3 years. II. Patient Type: Established Maintained professional services in the last 3 years. Maintained professional services in the last 3 years.

9 Billing for Problem Focus Visit Problem Focus Visit – presenting problem self limited or minor, the provider will spend 10 minutes face to face with the patient and/or family. Problem Focus Visit – presenting problem self limited or minor, the provider will spend 10 minutes face to face with the patient and/or family. New patient visit CPT New patient visit CPT Established visit CPT Established visit CPT 99211

10 Billing for Expanded Problem Focus Expanded Problem Focus – presenting problem low to moderate severity, provider spends 15 minutes face to face with patient. Expanded Problem Focus – presenting problem low to moderate severity, provider spends 15 minutes face to face with patient. New patient CPT New patient CPT Established patient CPT Established patient CPT 99213

11 Billing for Detailed Detailed – usually the presenting problem(s) are moderate to high severity & physical assessment typically 25 minutes face to face with the patient. Detailed – usually the presenting problem(s) are moderate to high severity & physical assessment typically 25 minutes face to face with the patient. New patient CPT New patient CPT Established patient CPT Established patient CPT 99214

12 Billing for Comprehensive Comprehensive – high complexity, multi- system exam or complete exam of a single organ system, lasting 40 minutes. Comprehensive – high complexity, multi- system exam or complete exam of a single organ system, lasting 40 minutes. New patient visit CPT New patient visit CPT Established patient visit CPT Established patient visit CPT 99215

13 E/M Coding: Level of Visit CPT CodeHistoryExamManagement Time 99211Minimal 5 minutes 99212Problem focused Straightforward10 minutes 99213Expanded problem focused Low complexity 15 minutes 99214Detailed Moderate complexity 25 minutes 99215ComprehensiveComplexHigh complexity 40 minutes

14 E & M Visit: Elements/Bullets Female exam consists of 11 elements – Female exam consists of 11 elements – - Inspection & palpation of breasts - Inspection & palpation of breasts - Digital rectal exam - Digital rectal exam - Pelvic exam - Pelvic exam - External genitalia - Cervix - External genitalia - Cervix - Urethral meatus - Uterus - Urethral meatus - Uterus - Bladder - Adnexa - Bladder - Adnexa - Vagina - Anus & perineum - Vagina - Anus & perineum

15 E/M Visit: Physical Examination LEVELSINGLE ORGAN SYSTEM EXAM Problem Focused Expanded Problem Focused Detailed Comprehensive 1-5 bullet elements 6 or more bullet elements 12 or more bullet elements Female GU exam, abdomen, constitutional, & other organs

16 ICD Codes

17 Defintion ICD (International Statistical Classification of Disease) are alphanumeric designations given to every diagnosis and description of symptoms! ICD (International Statistical Classification of Disease) are alphanumeric designations given to every diagnosis and description of symptoms! Describes why that service was provided. Describes why that service was provided. *Remember the CPT code describes the service that was *Remember the CPT code describes the service that was rendered for billing purposes. rendered for billing purposes. IDC-9 codes most commonly used codes, ICD-10 transition is very expensive, & most providers have not yet upgraded to the ICD-10 system. IDC-11, the next major update ( in the development).

18 ICD Codes Diagnostic Codes – identifies diseases, disorders, human response, & medical signs. Diagnostic Codes – identifies diseases, disorders, human response, & medical signs. Example Example Dx of GERD (acid reflux) code Dx of GERD (acid reflux) code

19 ICD-CM Coding Rules List the principal diagnosis first List the principal diagnosis first If diagnosis is not established, code for symptom If diagnosis is not established, code for symptom -Don’t code for “rule-out” diagnosis -Don’t code for “rule-out” diagnosis Don’t code a diagnosis that doesn’t apply to the present visit. Don’t code a diagnosis that doesn’t apply to the present visit. Preventive E/M codes linked to V codes. Preventive E/M codes linked to V codes.

20 What are V-Codes? Specific ICD-9 codes used to identify encounters for reasons other than illness or injury. Specific ICD-9 codes used to identify encounters for reasons other than illness or injury. Examples CPT ICD-9 description Examples CPT ICD-9 description Start OCs V prescription IUC insertion V Insertion of IUC Missing string V Presence of string STI evaluation V 01.6 Contact/exposure Pregnancy test V72.41 Test/exam-negative

21 Case Study “Screen Me For Everything” 28 y/o established fe request for STI screening….asymptomatic 28 y/o established fe request for STI screening….asymptomatic Monogamous relationship 4 months ago; unprotected sex with new partner 6 wks ago Monogamous relationship 4 months ago; unprotected sex with new partner 6 wks ago Pelvic exam negative; CT, GC, wet prep Pelvic exam negative; CT, GC, wet prep Wet prep negative, vaginal pH: 4.0 Wet prep negative, vaginal pH: 4.0 Blood drawn for HIV, VDRL, Hepatitis B, Hepatitis C Blood drawn for HIV, VDRL, Hepatitis B, Hepatitis C

22 Case Study: Answer CPT codeICD-CM code Procedure Supplies Drug Lab E/M Modifier None (microscopy) (vaginal pH) None V01.6 (STI exposure) or V69.2 (HRSB*) V01.6 (STI exposure) or V69.2 (HRSB*) *HRSB: high risk sexual behavior *Unnecessay tests Hep B,C

23 IN Summary Coding is: Coding is: Complex Complex Hard to remember Hard to remember Boring BoringBut: - It is how you are credited for the work you do - It is how you are credited for the work you do - It is often a determinant of how you are paid - It is often a determinant of how you are paid - It is how fee-for-service is paid - It is how fee-for-service is paid Therefore, DO IT WELL

24 Improve Your Coding Buy new CPT & ICD-9 books ANNUALLY Buy new CPT & ICD-9 books ANNUALLY Review coding issues & new developments at staff meetings. Review coding issues & new developments at staff meetings. Coding Resource Coding Resource ACOG web site: ACOG web site: - Quick Link - Coding - Quick Link - Coding


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