1. Developmental Screening Billing and Payment: Stories from the Front Line Michelle M. Macias, MD D-PIP Workshop 2 September 7, 2007 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

2. Importance of Accurate Coding u Improved Information Processing –Accurate diagnostic coding requires analyzing all provided information (subjective and objective) u Decreased Liability –Documentation F Medico-legal –Compliance u Increased Reimbursement –One minute of extra work can result in an increased code level

3. The Codes: ICD-9-CM and CPT u ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification –Why the service was done –Information collected by payers to manage risk (preexisting conditions; refused diagnoses) u CPT: Current Procedural Terminology –What was done –Provides the basis for payment

4. ICD-9-CM and CPT u Your financial success –or failure can be directly related to proper coding for both the diagnosis and the service(s) u The ICD-9-CM and CPT numbers MUST be used on the claims sheet – not written diagnostic descriptions –Claims denied, fines or penalties levied, even imposed sanctions!

5. ICD-9-CM u Physicians’ Current Procedural Terminology (CPT) codes for services are always reported to payers with diagnosis codes from International Classification of Diseases -9th edition, Clinical Modification (ICD-9- CM) u Important point: The Health Insurance Portability and Accountability (HIPAA) Act of 1996 requires payers and physicians to use ICD-9 CM. As revised ICD-9 CM codes are activated, you must use these updated codes. Obviously, these codes explain to payers the specific reason a patient was seen.

6. ICD-9-CM u The reason for the service (visit) u The first diagnostic code reflects the condition the professional is actively managing: –“the reason for the visit” u Subsequently listed codes –Factors important to condition #1 –Coexisting conditions tx. and management of #1 u If a child is seen for a residual condition (e.g. hearing deficit), code this first with the cause of the condition as a secondary ICD-9-CM code (e.g. meningitis)

7. ICD-9-CM “The Top→Down View” u Code to the highest degree of specificity u Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results u Probable, suspected, questionable, or rule out should not be coded u List the ICD-9-CM code that is identified as the main reason for the service first, then list co-existing conditions u Chronic disease treated on an ongoing basis may be coded u Do not code for conditions previously tx that no longer exist

8. ICD-9-CM u Do code only the conditions/problems you are actively managing at the time of the visit and diagnoses affecting the current status of the child u Do not code for previously treated conditions u May include conditions existing at the time of the patient’s initial contact as well as conditions developing subsequently affecting treatment u Dx. relating to a pt.’s previous medical problems w/ no bearing on the present condition are not coded.

9. ICD-9-CM u Do not code dx. listed as “rule out,” “probable” or “suspected” –they are not established in out-patient practice u Do code to the highest degree of certainty u Do not code symptoms if a dx. has been made: Eg.: If a child with ADHD is seen for routine med. monitoring and headaches are reported w/ meds.: code 314.01 first, then headache as #2.

10. ICD-9-CM u If a code has 5 digits, you must code to that 5 th digit! u Do not arbitrarily use a zero as a filler character when writing an ICD-9-CM code –The addition of a zero to a code number not requiring an additional digit can cause a claim denial u Fourth position numbers.8 (NEC: other specified) and.9 (NOS: unspecified) are usually ‘residual subcategories’

11. Developmental Examples u 783.42 Delayed milestones u 315.31 Language disorder, developmental u 315.9 Learning disorder, NOS u 348.3 Static encephalopathy u 781.3 Lack of coordination F Impairment of the ability to perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures. Loss of muscle coordination. F 781.3 is a specific code that can be used to specify a diagnosis F 781.3 contains 25 index entries, including dysdiadochokinesis, ataxia NOS, hypotonia, hypertonia Useful websites: u icd9cm.chrisendres.com/2007. The ICD-9-CM is maintained jointly by the National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS).

12. NEC and NOS u Residual Categories –NEC: Not elsewhere classifiable: conditions specifically named in the medical record but not specifically listed under a code description –NOS: Not otherwise specified: a diagnostic statement lacking detail in describing a specific condition (e.g. 314.9 unspecified hyperkinetic syndrome)

13. Pearls u Code the diagnosis to the highest level of certainty (the words in the descriptor) u Code the diagnosis to the highest level of specificity (the numbers in the descriptor)

14. Pearls u Remember, a chronic condition (e.g. delayed development) managed on an ongoing basis may be coded and reported as many times as applicable to the patient’s treatment. u The level of the E/M visit may change as the complexity of the child’s needs change.

15. V Codes u Are used to deal with occasions when circumstances other than a disease or injury are recorded as “diagnoses” or “problems” –When a pt. who is not currently sick, encounters a health provider for some specific service (e.g. weight check) –When a pt. presents for a specific tx. of a known condition or disease –When a pt.’s health status is influenced by some circumstance which is not in itself a current injury or illness (e.g. parental hx of alcoholism)

16. V Codes u V codes may be sequenced in the first position if the pt. was not seen for an active illness/injury u Be cautious when using V codes as 2 nd or 3 rd diagnoses because, as Medicare automatically denies these claims, many other payers who adopt Medicare policies may also deny the claim –Note: This may be especially true for clinics located in facilities who primarily serve adults –they adopt CMS policies rather than CPT

17. DB ‘V Codes’ u V40.0Problems with learning u V40.1Problems with communication (including speech) u V40.3Mental and behavioral problems; other behavioral problems u V40.9Unspecified mental or behavioral problem u V60.0Lack of housing u V60.1Inadequate housing u V60.2Inadequate material resources u V60.8Other specified housing or economic circumstances u V61.20Counseling for parent-child problem, unspecified u V61.29Parent-child problems; other u V61.49Health problems with family; other u V61.8Health problems within family; other specified family circumstances u V61.9Health problems within family; unspecified family circumstances u V62.0Other psychosocial circumstances; unemployment u V62.5Other psychosocial circumstances; legal circumstances u V62.81Interpersonal problems, NEC u V62.82Bereavement, uncomplicated u V62.89Other psychological or physical stress, NEC; other u V62.9Unspecified psychosocial circumstance u V65.49Other specified counseling u V71.02Observation for suspected mental condition; childhood or adolescent antisocial behavior u V77.0Special screening for thyroid disorders u V79.2Special screening for mental retardation u V79.3Special screening for developmental delays in childhood u V79.9Unspecified mental disorder and developmental handicap u V80.0Special screening for neurologic condition u V82.5Special screening for lead poisoning

18. Current Procedural Terminology (CPT) u Published by the AMA u Listing of the codes and descriptions for procedures, services and supplies u Used to bill insurance carriers

19. CPT Coding 5 Basic Principles of Use u Practitioner should select diagnosis and procedure codes u Document patient’s services to support codes (compliance) u Use separate codes for different encounters u Learn to use modifiers, testing and add-on codes u Design a superbill/computerized routing sheet

20. “RVU Review” u Resource Based Relative Value Scale (RBRVS) u Relative Value Units (RVUs): “The Coin of the Realm” u A numerical value (relative reimbursement) assigned to a CPT code u Calculated on –Amount of physician work –Practice expenses –Malpractice cost –Service location (office vs. hospital)

21. RVU Components of Physician Work u Pre-, intra-, post- service work –Time to perform the service –Technical skill and physical effort –Mental skill and judgment –Psychological stress associated with iatrogenic risk

22. Developmental Screening u 96110: Developmental testing, limited –Aka Developmental screening, with interpretation and report –Expectation is that the screening tool will be completed by a non-physician staff member and reviewed by the physician –No physician work is included in the RVU –Reported in addition to E/M services provided on same date, with modifier (-25) –Report for each screen administered –Medicaid may not pay separately for developmental screening when provided as part of Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT)

23. Developmental Testing u 96111: Developmental testing-extended –Used for extended developmental testing/evaluation typically provided by the medical provider –Used when ‘hands-on’ testing is completed –Includes the interpretation and report –Based on 1 hr of physician work (2.6 Work RVU) –Reported in addition to E/M services provided on same date, with modifier -25

24. Modifiers u Services altered by specific circumstance Tells insurer “this visit is different” - 21 Prolonged E/M Service -25 Significant separately identifiable E/M service by the same physician on the same day F Used to report developmental screening/testing with E/M code -32 Mandated Services -52 Reduced Services

25. Billing Stories: Challenges arising from inconsistent reimbursement policies “ “What we decided to do…was we brought the cost of the 96110 code down to something that was very nominal: five dollars….We have this rule that if the balance on the account is less than ten dollars it gets written off. So when it was five dollars they got written off.” The person for billing didn’t want us to bill for [developmental screening] because then the whole thing gets denied so we would have a lot of non-payment…she just advised us to not even circle it so we didn’t have problems from the billing standpoint if it wasn’t going to get paid for.” “The person for billing didn’t want us to bill for [developmental screening] because then the whole thing gets denied so we would have a lot of non-payment…she just advised us to not even circle it so we didn’t have problems from the billing standpoint if it wasn’t going to get paid for.”

26. Billing Stories “ “ My director said that [insurance carriers] will come back and say why them, why not everyone else? …everyone else may have to pay for it but your [Medicaid] patients don’t, so why is there a discrepancy? So we couldn’t bill for [developmental screening].” (Bottom line from their billing standpoint: if going to charge, have to charge everyone…if you can’t do that, don’t charge anyone) The billing service set the fee (~$110) for 96110. It wasn’t reimbursed so the fee got passed on to the patient without review by the provider. Providers were mortified. The billing service set the fee (~$110) for 96110. It wasn’t reimbursed so the fee got passed on to the patient without review by the provider. Providers were mortified.

27. Billing Stories: 96110 & 96111 u u Same carrier (depending on the plan): – –Bundled 96110 and did not pay separate fee – –96110 was covered and fee paid – –96110 not allowed and fee passed on to patient u u 96110 vs 96111 –96111 involves physician work (RVUs) and paid for, but 96110 wasn’t paid –Practice chose to bill 96111

28. Billing Stories: 30 month visit u Practices assumed 30 month visit wouldn’t be paid for, so didn’t call insurance company –If appealed, some would get visits approved –Some practices were advised by coders to ‘give it up’. Basically, billing was more trouble than it was worth as they would ultimately have to reverse the charges