1. Coding, Documentation, and Data Management Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs

2. Session Objectives zUnderstand basic code systems zUnderstand basic organization and principles of procedure and disease coding zUnderstand basic principles of coding and billing zUnderstand basic principles of documentation

3. Topics for Discussion zCoding systems zProcedure codes zDisease codes zCoding, billing, and compliance zDocumentation zReferral guidelines and service agreements

4. How are codes used? zRevenue generation (reimbursement) zDocumentation of services zWorkload and utilization zProductivity zCost analysis zProvider profiles (privileging) zAnalysis, health research, and trending

5. Coding Systems

6. Procedure Coding Systems zHealthcare Common Procedure Coding System (HCPCS) zCurrent Procedural Terminology (CPT) zHCPCS Level II (National or HCPCS) zICD-9 PCS  Future: ICD-10-CM and ICD-10 PCS

7. Disease Coding zInternational Classification of Diseases, Ninth Edition, with Clinical Modifications (ICD-9-CM) zFuture: International Classification of Diseases, Tenth Edition (ICD-10-CM)

8. Professional & Technical zCodes may not have physician work value zSome codes have technical (TC) and professional (26) components. zProfessional component=physician work (May be billed by audiologists.) zTechnical component=practice expense zMost Audiology codes do not have physician work.

9. Complexity-based Codes zUnless otherwise specified, procedures are based on complexity  Enter one code per procedure regardless of time spent zMost CPT codes are complexity-based.

10. Time-based Codes zTime period is specified (e.g. 15 minutes) zEnter one code for each time period zTotal volume=total time  Example: 2 units=30 minutes for a 15- minute procedure zFew Audiology codes are time-based. zTime must be documented.

11. Audiology Services zCPT codes in the 92500-series zTechnical and professional services zDo not require supervision by a physician zPerformed by qualified audiologists zMust be ordered by a physician to be billed.

12. General Purpose Codes z92506--evaluation of auditory processing and/or aural rehabilitation status z92507--treatment of auditory processing disorder (includes aural rehabilitation) z92508--group treatment zOften used (and abused) for hearing evaluation and treatment, not elsewhere classified

13. Audiology Treatment Codes zAudiologists cannot be reimbursed for treatment services under Medicare y69200--foreign body removal y69210--cerumen management y97112--vestibular rehabilitation

14. Implant Services zCochlear implant evaluation: Use audiological assessment codes zPost-op analysis and fitting: y92601--Diagnostic analysis of CI, <7 yoa y92602--Subsequent programming, < 7 yoa y92603--Diagnostic analysis of CI, >7 yoa y92604--Subsequent programming, > 7 yoa zBillable as diagnostic services zCI Rehab (treatment)--92510 or 92507?

15. Vestibular Function Tests zWith electrical recording y92541--spontaneous nystagmus test y92542--positional nystagmus test y92543--caloric vestibular test, each irrigation y92544--optokinetic nystagmus test y92545--oscillating tracking test (pursuit)  92546--sinusoidal vertical axis rotation test

16. Vestibular Function Tests z92547--use of vertical channel recording zAdd-on code--usually limited to 92541 and 92542 zNo specific code for saccades (use 92700)

17. Vestibular Function Tests zObservation without electrical recording zNo reimbursement value y92531--spontaneous nystagmus y92532--positional nystagmus y92533--caloric vestibular test y92534--optokinetic nystagmus

18. Audiological Assessment Codes z92551--screening test, air only z92552--pure tone audiometry, air only z92553--pure tone audiometry, air/bone z92555--SRT z92556--SRT and speech recognition zNo code for PI/PB (use modifier 22)

19. Audiological Assessment Codes z92557--comprehensive audiometry zBundled code (includes 92553 and 92556) zDo not code separately if all component tests are performed z92559--group audiometric test

20. Middle-ear Function Tests z92567--acoustic immittance (tympanometry) z92568--acoustic reflexes z92569--acoustic reflex decay

21. Site of Lesion Tests z92571--filtered speech test z92572--SSW z92576--SSI (ICM or CCM) z92563--tone decay test z92564--SISI z92565--pure tone Stenger test z92577--speech Stenger test z92589--central auditory function test

22. Less Commonly Used Procedures z92573--Lombard test z92575--SAL z92562--loudness balance test (ABLB) z92560--Bekesy screening test z92561--Bekesy diagnostic test

23. Electrophysiological Tests z92584--electrocochleography z92586--auditory evoked potentials, screening z92585--auditory evoked potentials (ABR, MLR, late potentials), diagnostic z92587--otoacoustic emissions, screening z92588--otoacoustic emissions, diagnostic z95920--intraoperative monitoring (added on to primary procedure, e.g. 92585)

24. Hearing Aid Services z92590--HAE, monaural z92591--HAE, binaural z92592--hearing aid check, monaural z92593--hearing aid check, binaural zV5014--hearing aid repair z92594--electroacoustic test, monaural z92595--electroacoustic test, binaural

25. Hearing Aid Services zProgramming--Use 92594 or 92595 zEar impression--V5275 zReal-ear measurement--V5020 zOtoscopy is part of examination and is not coded separately. Video-otoscopy is diagnostic and is coded as 92700.

26. Hearing Aid Services z97703 (each 15 min)--hearing aid orientation z92506--outcome measures z92507-aural rehabilitation (except implant) zConsidered to be part of fitting*: ydevice ordering/handling (99002) yspecial supplies (99070) ypatient education materials (99071) ygroup patient education (99078) z*not billable by audiologists

27. Balance Treatment zAudiologists treat vestibular disorders including BPPV. zPeripheral vestibular rehab (canalith repositioning) is within the audiologist’s scope of practice. Code 97112. zPT/OT treats global balance problems (sensory integration, proprioception). zDynamic posturography (92548) is within the PM&R scope of practice. zGlobal vestibular rehabilitation (97112).

28. Audiology: HCPCS Codes zV5008-hearing screening zV5010-V5298--hearing aid services zV5299--miscellaneous hearing service zL8614--cochlear implant device/system zL8619--speech processor replacement zL7510--repair of prosthetic device (not hearing aid)

29. CPT Modifiers

30. Why Use Modifiers? zTo indicate that a service was more or less complex than typical zTo indicate that a service was repeated or discontinued zTo add more information regarding the purpose or anatomic site of the procedure zTo help to eliminate the appearance of duplicate billing  To help to eliminate the appearance of unbundling (fragmentation).

31. CPT Modifiers z22--unusual procedural service z26--professional component (interpretation) z51--multiple procedures during same encounter z52--reduced service. Example: unilateral procedure when bilateral is assumed.

32. CPT Modifiers z53--discontinued procedure z59--distinct procedural service on same day z76--repeat procedure by same provider z77--repeat procedure by other provider z99--multiple modifiers

33. Disease Coding

34. Structure of ICD-9-CM z3-, 4-, and 5-digit codes indicating levels of specificity zUpdated annually by working group zDiseases and injuries (001-999) zFactors influencing health status and contact with health services (V-codes) zExternal causes of injury or poisoning (E- codes)

35. Principles of Disease Coding zGeneral rule: code to the highest degree of medical certainty. zUse the most specific code possible. zAvoid NOS and NEC codes. zNon-physicians may code symptoms. zChoice of disease code has a great affect on reimbursement.

36. NEC and NOS Codes zNEC--not elsewhere classified (xxx.x8) zNOS--not otherwise specified (xxx.x9) zNEC means that no appropriate code was found in the tabular list based on the information provided. zNOS means that the condition was not adequately described by the provider. zNOS codes are usually not accepted

37. Outpatient Disease Coding zCondition that is chiefly responsible for the patient’s visit is the primary diagnosis. zPrimary diagnosis may be a disease, condition, problem, symptom, injury, or reason for encounter. zSecondary diagnoses may describe co-existing conditions, symptoms, or reasons zDo not code conditions previously treated and no longer exist. zDo not code “probable”, “suspected”, “questionable”, or “rule out” diagnoses.

38. Primary and Secondary zPrimary Diagnosis: disease, symptom, condition or reason that is chiefly responsible for the visit. zSecondary Diagnosis: other diagnoses (e.g. relevant chronic conditions), conditions that have impact on care, or other conditions found after study.

39. Primary and Secondary zFor treatment services: yPrimary Diagnosis: reason that is chiefly responsible for the visit. ySecondary Diagnosis: Condition treated and other diagnoses (e.g. relevant chronic conditions) or other conditions found after study.

40. Primary and Secondary zFor assessment services: yPrimary Diagnosis: appropriate V-code to indicate the reason for the exam ySecondary Diagnosis: any diagnoses, conditions, or symptoms found after study

41. V-codes zDo not confuse ICD-9-CM V-codes with HCPCS Level II V-codes. yICD-9-CM codes are diseases, conditions, symptoms, or reasons. yHCPCS Level II codes are procedures.

42. Audiology: ICD-9-CM V-codes zV19.2 (family history of hearing loss) zV19.3 (family history of ear disorder) zV41.2 (problems with hearing) zV53.2 (fitting/adjustment of hearing aid) zV65.2 (non-organic condition) zV65.43 (counseling for injury prevention) zV71.8 (observation for suspected condition) zV70.5 (exam for military personnel)

43. Normal Function zThere is no ICD-9-CM code for normal function. Normal function is not coded as a disease. zV65.5 when there are no risk factors. zV71.89 when there is clinical reason to suspect a problem.

44. Coding and Billing

45. Caveats zEvery insurance carrier has its own rules. zCoding is not the same as billing. zCoding errors may lead to billing errors zEven accurate coding may lead to errors. zNot all billed codes are reimbursable. zNot all encounter codes are appropriate or billable. zBilling errors, however innocent, may be viewed insurance fraud.

46. What is Required to Assure Accuracy (compliance)? zBilling codes must match documentation. zDocumentation must support the scope and level of service (complexity or time). zCPT codes must match diagnosis. zServices must be appropriate by provider type. zServices must be ordered by a physician (in writing)

47. Reasons for Fraudulent Billing zInadequate documentation zImproper coding zServices not provided zFragmentation (unbundling) zLack of medical necessity

48. Role of the Provider zFully document clinical care zProvider is responsible documentation zUse accurate encounter forms zEncounter form is a tool. Documentation is what is important. zFollow applicable coding and documentation guidelines zAssist in verifying claims

49. What Can Be Done to Improve Coding? zCoding handbooks and guidelines zStandard encounter forms (super bills) zEducation zGood dialogue with coding and billing officials zElectronic aids (templates, code filters, prompts, taxonomies, e.g. CHCS-2)

50. Documentation

51. Principles of Documentation zDocumentation must be: yAccurate--describes the care provided yCodable--supports CPT, ICD, DRG codes yUnderstandable--clear to reader yTimely--written at time patient was seen yError free--stands alone as a legal document

52. Principles of Documentation zIf ain’t documented, it weren’t done! zAll care must be documented. zAnecdotal or historical events (patient not present) should be documented. zAll documentation must be dated and signed.