Presentation on theme: "Breaking the Code: ICD, CPT, HCPCS, DSM, E & M, EPF, SF, EI-MH"— Presentation transcript:
1 Breaking the Code: ICD, CPT, HCPCS, DSM, E & M, EPF, SF, EI-MH
2 Objectives Demonstrate, through interactive exercises, knowledge of basic coding principles andpotential consequences of inaccuratecodingDefine the acronyms in our workshop titleand state the purpose of various diagnosticand procedural coding systems currently inuseState at least 4 of 7 reasons why accuratecoding is important to School Health Centerpractice
3 ObjectivesDemonstrate ability to select the appropriate CPT Evaluation and Management Codes as demonstrated through interactive coding exercisesDemonstrate knowledge of other physical health procedure codes commonly used in school health center settings
5 Types of Coding Current Procedural Terminology (CPT) International Classification of Diseases (ICD-9 Clinical Modification - CM)Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association. CPT codes accurately describe medical, surgical, and diagnostic services and is designed to communicate standard information about medical services and procedures between physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The current version is the CPT 2007.The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides 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. Such categories can include a set of similar diseases.The International Classification of Diseases is published by the World Health Organization. The ICD is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The most current edition is the ICD-10, with ICD-11 to be released in 2011.An important alternative to the mental disorders section of the ICD is the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the primary diagnostic system for psychiatric and psychological disorders within the United States and some other countries, and is used as an adjunct diagnostic system in other countries. Since the 1990s, the APA and WHO have worked to bring the DSM and the relevant sections of ICD into concordance, but some differences remain. The current version is the DSM-IV-TR, which a new version to be released in the next year or two.5
6 Coding Translates Words into Numbers Procedure codes indicate what was done. (e.g. CPT; HCPCS / Health Care Procedure Coding System)Diagnosis codes justify why it was done. (e.g. ICD-9-CM; DSM-IV-TR)6
7 Over-coding and Under-coding CPT and ICD-9 codes must always relateThe first ICD-9 code you use drives the relationship to the CPT codeJust to reiterate:CPT and ICD-9 codes must always relateThe first ICD-9 code you use drives the relationship to the CPT code7
8 School Health Center Coding There is no difference between coding in a SHC and any other setting – the coding assumptions are the same.You provide the same level of care regardless of the location.Some people believe that you can only use certain codes because you are a SBHC, but this is not true. The care provided in and SBHC is of the same level as care provided in any setting.8
9 Why is it important for providers to code appropriately? Tell your storyDocumentationReimbursementMedical LiabilityRisk of Medicaid Review/AuditProvider ProfilingPatient LabelingEpidemiological TrackingInternal Tracking9
10 When a provider is under-coding they tell the wrong story The wrong story is:SHC providers are seeing very few patients with multiple problemsSHC providers should see more patients since they are not seeing complicated patientsThe SHC should decrease the number of physicians and add more mid-level providersAssumptions will be made by others about what you did by virtue of what you code. The American Academy of Pediatrics reports each year that a majority of its members under code.These assumption are not true and can be reversed by accurate coding.10
11 Fraud Intentional deception or misrepresentation Deliberately billing for services not performedUnbundling of servicesIntentionally submitting duplicate claimsFraud is an intentional act of deception or misrepresentation. People get really antsy about fraud, but remember they key is that it is intentional.11
12 Abuse Improper billing practices Billing for non-covered services Misusing codes on a claim formAbuse is termed as improper billing practice. The focus here is only billers, not providers.12
13 Errors Accept it; you will make them Your best defense is having a plan for your coding and being able to explain itWe all make mistakes, so don’t be afraid of an audit. If you are audited, have your guidelines handy so you can show why you coded as you did. Auditors will tell you if you made an error. Keep in mind that under coding is also an error and subject to the same fines as over coding.13
15 But - Coding Requires Good Documentation to Justify the Code Selected 15
16 General Coding Principles Coding gets you paid for your servicesCoding can be used to justify the need for services to your fundersAnd, this good documentation can get you paid for your services and can be used to justify the need for services to your funder.16
18 ICD-9-CM Coding Used by all insurers Codes are made up of 3, 4, or 5 digits (numeric or alphanumeric)Codes are updated annuallySource documents should support the diagnosis code(s) selectedFailure to code properly can result in fines, sanctions or decreased revenue18
19 ICD-9-CM Code Book Volume 1: Disease Tabular Index Notes all exclusive terms and 5th-digit instructionsVolume 2: Alphabetic Index of DiseasesDoes not contain detail; do not code from this volumeVolume 3: ICD-9-CM Procedure CodesOnly used by hospitals to report inpatient procedures19
20 ICD-9-CM Codes Range from 001.0 to V89.09 They identify: Diagnoses SymptomsConditionsProblemsComplaintsOther reason for the procedure, service, or supply providedICD-10 codes identifyDiagnosesSymptomsConditionsProblemsComplaintsOther reason for the procedure, service, or supply provided20
21 ICD-9-CM Coding Examples Streptococcal PharyngitisTobacco AbuseAcute Bacterial PneumoniaDysmenorrheaAsthmaDermatitis due to sunburnObesity21
23 V-Codes Used when patient is not currently sick To classify factors influencing health status.(e.g. Pregnancy; Family/Personal HealthHistory)To classify type of contact with health services.(e.g. Well Child Check-up; Sports Physical)Alphanumeric CodeV-Codes can be problem-oriented, service oriented or factual23
24 “V” Codes Can be used as a: Solo Code Principal Code Secondary Code V codes can be used in several ways (we’ll talk about these later) and may represent check-ups, screenings, administrative request, or prescription refills.24
25 Coding Tip! History (of) Aftercare Observation (for) Checking When locating a V-Code in the Alphabetic Index, use the reason for the visit as the main term.Common terms in alphabetic index where V-codes are found include:History (of)Observation (for)Problem (with)Screening (for)VaccinationAftercareCheckingCheckupExaminationFollow-up25
26 V-Codes V-Codes are used for: Routine examinations Aftercare Follow-up examinationsPre-op examinationsCounselingScreening26
28 Always a secondary diagnosis ICD-9-CM CodingE Codes(External Causes of Injury or Poisoning)Always a secondary diagnosisOptional Codes-Use with cautionHow an accident occurredWhat caused an injuryWhether a drug overdose was accidentalAn adverse drug reactionLocation of occurrence28
29 Coding Tip! Whenever possible, avoid ICD-9-CM Codes that are labeled: NEC - not elsewhere classified ORNOS - not otherwise specifiedAlways code to the highest level of specificity (5th digit) if possible.29
30 Coding Tip!Do not code diagnoses documented as “probable”, “suspected” or “rule out” as if the diagnosis is established.In these instances code the symptoms, signs, abnormal test results or other reason for the visit.If no condition or problem is documented at the end of the visit, code the documented chief complaint or symptom.30
31 Coding Tip!First diagnosis code should describe the chief reason for the service.Link procedures with justifying diagnosis.31
32 Coding Outpatient Physical Health Visits and Services
33 Types of Outpatient Visits and Services to Be Discussed Nurse-Only VisitsPreventive Medicine Service CodesScreening/Counseling CodesImmunization CodesNutrition CodesSurgical CodesPulmonary/Respiratory CodesOther Codes (HCPCS; Supply Codes)
34 New Patient vs. Established Patient A “new” patient is one who has not received any professional service from the health care provider, or another provider of the same specialty who belongs to the same group practice, within the past three years.An “established” patient is one who has received a service, according to the latter definition, within the past three years.
35 Determining Medical Necessity Services or procedures that are justified as reasonable and necessary for the diagnosis and treatment of an illness or injuryAll payors define medical necessity differentlyThe clinical rationale for performing the services or procedures must be documented through coding and in the medical record
36 Nurse-Only VisitsCPT – Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.Triage – Non-billable RN contact (report only). Some states have statewide local use codes for HD’s and SHCs funded by DPH).“Frequent flyer” pattern of new patient visits.Triage or “mommy visits” that will typically be non-billable versus RN visits that require more in-depth evaluation and management that the SHC plans to bill.While some diagnoses may be more likely to result in “mommy visits”, ultimately the treatment/procedures performed should guide whether the service is billable.Structure the encounter form / RN treatment protocols such that subjectivity is minimized.
37 Preventive Medicine Service Codes (CPT 99381-99397) Code choice based on age & new vs. establishedIncludes age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic proceduresImmunizations (admin fees & vaccines), certain screening services and any diagnostic tests should be coded separatelySome of these will be considered “add-on” codes for billing purposes (See slides #43-45 for examples of “add-on” codes)The term “comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examComprehensive for a preventive service means that all of the components of a well child check-up have been performed, including a thorough well child exam.A “comprehensive exam” for the purposes of an E&M office visit means that 8 or more “body areas” or “organ systems” have been examined. This will be reviewed by Kathleen Loucks in the next section of this presentation.
38 Preventive Medicine Service CPT Codes [Used with ICD-9 Diagnosis Code V20.2 “Routine infant or child health check”]AgeNewEstablished<199381993911-499382993925-11993839939312-17993849939418-399938599395
39 Acute Problems within a Comprehensive Physical Preventive health visit (V20.2) with a significant, separately identifiable, acute health problem,List both the preventive health visit code (first) and the acute visit code (second)Provider must list ICD-9 codes that justify bothBilling department must add a modifier (-25) –“Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”What is OH’s Medicaid Policy on this?NC the Medicaid policy is as follows:“A Health Check screening assessment and an office visit cannot be paid initially on the same date of service. One claim will pay and the other will deny. For the denied claim to be reconsidered, it must be submitted as an adjustment with medical justification and a copy of the Remittance and Status Report (RA) denial attached.”
40 Screening / Counseling Codes (Preventive Medicine Service “Add On” CPT Codes) 92551 – Hearing screening test99173 – Screening test of visual acuity, quantitative, bilateralLaboratory tests related to dyslipidemia, STDs, pregnancy, wet prepHealth and Behavioral Assessment codes – performed by Qualified Behavioral/Mental Health Provider, must provide medical (not behavioral health) ICD-9-CM Code (e.g. diabetes; asthma; etc.)– Smoking & Tobacco Use Cessation Counseling– Alcohol &/or Substance (other than tobacco) Structured Screening and Brief Intervention99420 – Admin. & Interpretation of Health Risk Assessment Instrument:Health Risk Appraisals: Bright Futures, GAPS, HEADSSS, or Modified ToolEvidence-Based Mental Health Screening Tools (e.g. PSC, SDQ, PHQ-9, BDI-PC)Dyslipidemia: Lipid Panel – CPT (Must include Total Serum Cholesterol (82465), HDL (CPT 83718); Triglycerides (CPT 84478).VLDL is CPT 83719; LDL is CPTSTD Screening: Chlamydia – Culture (CPT = 511); Direct Probe (CPT = 109); Amplified Probe (CPT = 856)Gonorrhea – Direct Probe (CPT = 648); Amplified Probe (CPT = 778)HIV – For HIV 1 (CPT = 676); For HIV 1 & 2 (CPT = 2)Syphilis – VDRL, RPR, ART (CPT = 599)Hepatitis B – Acute Hep Panel (CPT = 10); Hep B Surface Antibody (CPT = 10)Herpes – Antibody; herpes simplex, type 2 (CPT = 3)Trichomonas – (CPT & = None reported)Culture Codes (CPT & 87081)Wet Prep Code (CPT 87210)Pregnancy Tests:Urine Pregnancy Test, Visual Color Comparison (CPT = 2,374); hCG Quantitative (CPT = 63); hCG Qualitative (CPT = 19)
41 Immunization Codes Immunization Administration Codes For Injections:CPT (Initial Vaccine)CPT (Each Additional Vaccine)For Intranasal or Oral VaccinesCPT (Initial Vaccine)CPT (Each Additional Vaccine)Vaccine Codes (CPT )There are big changes coming with vaccine administration coding in CPT In the new vaccine administration coding scheme, the provider will code for administration of each “component” antigen in combination vaccines. With the introduction of more combination vaccines and the continued use of existing combination vaccines, a disconnect has been created between the work that is required in counseling and administering such vaccines and the payment for them. With the introduction of CPT Codes (for first vaccine/toxoid component) and CPT (for each additional vaccine/toxoid component), the level of effort will be documented and compensated. No guidance has been published to date and this information has only recently been released in November 2010.
42 Adolescent Vaccine Codes*** CPT CodeICD-9 CodeHepatitis A [HepA]90633V05.3Hepatitis A-Hepatitis B [HepA-HepB]90636V06.8Human Papilloma Virus [HPV4]90649V04.89Influenza, Split Virus, Preservative Free90656V04.81Influenza, Split Virus90658Influenza, Live, Intranasal90660Measles, Mumps & Rubella [MMR]*90707*V06.4Polio, Inactivated [IPV]*90713*V04.0Tetanus & Diptheria Toxoids [Td]90714V06.5Tetanus, Diptheria Toxoids & Acellular Pertussis [Tdap]*90715*V06.1Varicella*90716*V05.4Pneumococcal Polysaccharide, 23-Valent [PPV23]90732V03.82Meningococcal, Serogroups A,C,Y,W-135 (tetravalent)[MCV4]90734V03.89Hepatitis B* [HepB]90744*What vaccines are required by OH for school entry?
43 Nutrition Codes Medical Nutrition Therapy Codes CPT – Initial Assessment & Interventioneach 15 minutesCPT – Re-Assessment and InterventionCPT – Group MNT (2 or more youth)each 30 minutesNon-Billable Nutritionist ContactSome HDs and DPH use statewide local use code(s) to capture data on non-billable nutrition contacts
44 Surgical Codes [CPT ]Most commonly used surgical codes in SHCs:Incision and Drainage of Absess, Single10061 – Incision and Drainage of Absess, Multiple1975 – Insertion, Implantable Contraceptive Capsules11976 – Removal, Implantable Contraceptive Capsules11981 – Insertion, Non-Biodegradable Drug Delivery Implant11982 – Removal, Non-Biodegradable Drug Delivery Implant17000 – Destruction of Lesion or Wart, Single17003 – Destruction of Lesion or Wart, 2+29130 – Application of Finger Splint36415 – Collection of Venous Blood by Venipuncture69210 – Removal of Impacted Cerumen
45 Pulmonary / Respiratory (CPT 94010-94799) If a significant, separately identifiable service is performed unrelated to the technical performance of the pulmonary function test, an evaluation and management service may be reportedAttach -25 modifier to the E/M code.Previous differing guidance regarding how to code “peak flow”current recommendation CPT code 99211
46 Other Codes HCPCS Supply Codes A Codes – Medical and Surgical Supplies J Codes – Drugs Administered Other Than Oral MethodSupply CodesCode only supplies and materials provided over and above those usually included with the office visit or other services rendered.HCPCS (A Codes) or CPT – Depending on the insurance carrier.Examples of Codes Used by SHCs:A Codes for Slings; Splints; Asthma Related SuppliesJ Codes for Rocephen (29); DepoProvera (680); Implanon (55); Albuterol (29)
47 Local Use CodesCodes developed by local organizations to capture data on services for which there are no legitimate, nationally-recognized codesImportant not to use a nationally-recognized code illegitimately for a different purpose than the code definition.Could result in accidental billing and an audit finding.Be safe - avoid use of local use codes resembling a CPT or HCPCS Code.
49 Psychiatric Therapeutic Procedures CPT Codes – 90889Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.
50 Mental Health Procedure Codes Psychiatric Diagnostic or Evaluative Interview ProceduresPsychotherapyOffice or Other Outpatient FacilityInteractive PsychotherapyInpatient Hospital, Partial Hospital or Residential Care FacilityOther PsychotherapyOther Psychiatric Services or Procedures
51 E&M Codes and MH CodesThe Evaluation and Management services should not be reported separately, when reporting codes:90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827,
52 Data Collection and Billing: Encounter Forms and Superbills
53 Encounter Form / Super Bill Next we are going to discuss the coding steps and the rules that govern these rules. It may seem a bit confusing at first, but it is important that you understand the rules and then the explaination will follow
62 Reimbursement IssuesE&M codes, counseling, and preventive service codes are limited to physicians, PAs, NPs, nurses, and sometimes dieticians /nutritionistsSame is true for mental health codes 90805, 90807, codes because include medication evaluationIn some states an E&M (992XX) and a therapy (908XX) from the same medical sponsor cannot be billed on the same date of service to most Medicaid programs – this is changing
63 Reimbursement RatesReimbursement Rates can be reduced by provider typePediatrician/Family Physician - not discountedNP, PA - discounted in some statesPsychiatrist - not discountedClinical Psychologist - discountedLCSW - further discountedOther - discounted if covered
70 “Breaking the Code” Game Show Coding BasicsIncorrect Coding ConsequencesICD-9 CodesCPT CodesPhysical Health Codes100100100100100200200200200200300300300300300400400400400400500500500500500Final Question70
72 CMS Coding Guidelines 1995 vs.1997 Both 1995 and 1997 guidelines are approved for use by CMSAgencies should specify use of 1995 or 1997 guidelines in their administrative policiesThis lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version
73 Evaluation & Management (Office Visit) Coding Evaluation/Management (E/M) Servicesvisits and consultations furnished by health care providersNew Patient vs. Established PatientNew Patient (CPT ): one who has not received any professional service from the health care provider, or another provider of the same specialty who belongs to the same group practice, within the past three yearsEstablished Patient (CPT ): one who has received a service, according to the latter definition, within the past three years
74 Building a Framework for Selecting the Appropriate Office Visit Code Coding choices are made based on the building blocks that define the level of an E&M Office Visit Service
75 Components Used to Select the Level of E/M Service Timemay be considered the key or controlling factor to qualify for a particular level of E/M services when> 50% of the provider / patient visit time is spent doing counseling or coordination of careOR
76 Components Used to Select the Level of E/M Service Three components:History (Subjective Findings)Examination (Objective Findings)Medical Decision Making(Assessment & Plan)New patient codes (CPT ) require that all three key components be satisfied.Established patient codes (CPT ) require that two of three components be satisfied.
77 Time /Counseling /Coordination of Care CPT states, “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then (and only then) may time be considered the key or controlling factor to qualify for a particular level of E/M services.”Counseling may include: discussion of test results, diagnostic/treatment recommendations, prognosis, risk/benefits of management options, instructions, education, compliance or risk-factor reduction.
78 Evaluation & Management Visits > 50% of Time Spent in Education/Counseling Outpatient -- NEWCodes9920199202992039920499205Times (min)10”20”30”45”60”Outpatient - ESTABLISHED99211992129921399214992155”15”25”40”Documentation should reflect:The actual time spent in face-to-face contact with the patient>50% of the encounter involved counseling or coordination of careThe nature of the counseling/coordination of care activities(e.g.: counseled patient regarding smoking cessation)
79 Evaluation/Management (Office Visit) Services – Three Components New PatientEstablished PatientN/ALevel 1: – MinimalLevel 1: – PF; PF; SFLevel 2: – PF; PF; SFLevel 2: – EPF; EPF; SFLevel 3: – EPF; EPF; LCLevel 3: – D; D; LCLevel 4: – D; D; MCLevel 4: – C; C; MCLevel 5: – C; C; HCLevel 5: – C; C; HCFor First Bullet:There are 5 different levels of service (for new and established office visits) based upon the extent and type of treatment provided and the provider resources expended in providing the service (skill, knowledge, time, responsibility).The slides that follow provide further clarification about the building blocks that define level of service.5 different levels of service (CPT code numbers for “new” vs. “established” visits do not match for the 5 levels of service)The history & exam are classified as Problem Focused (PF); Expanded Problem-Focused (EPF); Detailed (D) and Comprehensive (C).Level of medical decision making is ranked as Straightforward (SF); Low Complexity (LC); Moderate Complexity (MC) and High Complexity (HC).
80 Selecting the Correct Office Visit Level for a “New” Patient * Requires 3 components in one column be met or exceededto select that CPT code level.HistoryPFEPFDCExaminationComplexity of Medical Decision-MakingSFLMHAverage Time(Minutes)10”20”30”45”60”Level1CPT 992012CPT 992023CPT 992034CPT 992045CPT 99205Time vs. 3 Components Move time below…
81 Selecting the Correct Office Visit Level for an “Established” Patient * Requires 2 components in one column be met or exceededto select that CPT code level.HistoryMinimal problem thatmay not requirepresence of medical provider.PFEPFDCExaminationComplexity of Medical Decision-MakingSFLMHAverage Time(Minutes)5”10”15”25”40”Level1CPT 992112CPT 992123CPT 992134CPT 992145CPT 99215
82 CPT 99211 – Minimal Service for an Established Patient CPT – Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically 5 minutes are spent performing or supervising these services.Service is provided under supervision of a “primary care provider” in some states medical provider must be a physician. (e.g. RN visit under “standing medical protocols” is the most common use of CPT in a School Health Center setting).If this code is used, it states that the expertise of a medical provider is not necessary. This code is not required to meet the three key components (history, exam and medical decision-making) in order to be used for coding / billing purposes.
83 Key Elements for History Component Chief Complaint (CC)Must be identifiable for EVERY patient encounterHistory of Present Illness (HPI)A description of the development of the patient’s present illness/symptoms since last clinic encounterReview of Systems (ROS)A review/inventory of associated symptoms within each of the fourteen body systemsPast, Family, and/or Social History (PFSH)A review of patient’s past medical/surgical history as well as familial and social history
84 History of Present Illness (HPI) HPI includes the following elements.*Location:Where is the sign or symptom occurring?Timing:When and how frequently does the sign or symptom occur?Quality:What is the character of the sign or symptom?Context:Are there any activities/situations associated with symptoms?Severity:How hard is it to endure? Pain scale useful.Modifying Factors:What makes the symptoms worse or better?Duration:How long has patient suffered with this symptom?Associated Signs / Symptoms:Are there any other bodily complaints associated with problem?Table with HPI at top and 2 columns and 4 rows.* Each element counts as one. Maximum score 8.
85 Review of Systems (ROS) A review/inventory of associated symptoms within each of the14 body systems14 Systems*Constitutional symptomsEyesEars, Nose, ThroatCardiovascularRespiratory14 Systems (cont)GastrointestinalGenito-urinaryMusculoskeletalIntegumentaryNeurologicalHematologic/LymphaticEndocrinePsychiatricAllergic/ImmunologicSame table here…* Each system counts as one. Maximum score is 14.
86 Past, Family, and /or Social History* (PFSH) Past Medical/Surgical History:A review of previous medical/surgical problems/treatments; medications; allergies (medication, food, etc); immunization status.Family History:A review of medical events in the patient’s family which may be hereditary or place the patient at risk.Social History:A review of patient’s past/present living conditions (school performance, school/community activities, relationships with family /friends, alcohol/drug/ tobacco use, sexual history, employment, etc)* Each type of history counts as one. Maximum score is 3.
87 EXPANDED PROBLEM- FOCUS History Component Scoring Tool (Number of elements for HPI, ROS & PFSH required for each level*)PROBLEM-FOCUSEDEXPANDED PROBLEM- FOCUSDETAILCOMPREHENSIVECCRequiredHPIBrief(1-3 elements)Extended(>4 elements)ROSNonePertinent to Problem(1 system)(2-9 systems)Complete(> 10 systems)Can count “all others negative”.PFSHPertinent(New=2 hx areas) (Est. = 1 hx area)(New = 3 hx areas)(Est. = 2 hx areas)* Overall history level is determined by the column marked furthest to the left.
88 Key Elements for Examination Component Involves examination of one or more of 7 body areas or 14 organ systems (1995 General Multi-System Exam Guidelines)*:Body Areas:Head/faceNeckChest/breasts/axillaeAbdomenGenitalia/groin/buttocksBack/spineEach extremityOrgan Systems:Constitutional(Vital Signs; Wgt Loss; Gen Appearance)EyesEars/Nose/Mouth/ThroatCardiovascularRespiratoryGastrointestinalGenitourinaryTable like previous slides…MusculoskeletalIntegumentary (Skin)NeurologicalPsychiatricHematologic/LymphaticEndocrineAllergic/Immunologic* Each body area / organ system counts as one.
89 Examination Component Scoring Tool PROBLEM-FOCUSEDEXPANDED PROBLEM- FOCUSEDDETAILEDCOMPREHENSIVEExamination1 body area / organ system2-7 body areas/ organ systems8 or more body areas/ organ systems
90 Key Elements for Medical Decision-Making Component Takes into account the complexity of establishing a diagnosis and/or selecting a management optionConsiders the following elements in assessing level of complexity of decision-making:Number of possible diagnoses/management options that must be consideredRisk of complications, morbidity and/or mortality as well as co-morbidities associated with patient’s presenting problem(s)Amount/complexity of medical records, diagnostic tests, and /or other information that must be obtained, reviewed, and analyzedData & diagnoses/treatment options are assigned points**Medical decision making is scored based on those points
91 Medical Decision-Making A. Number of Diagnoses or Treatment Options Problems to Examining ProviderNumber X Points = ResultSelf-limited/minor (stable, improved, worsening)1Max=2Est. problem (to examiner); stable, improvedEst. problem (to examiner); worsening2New problem (to examiner); no added work-up planned.3Max=3New problem (to examiner); added work-up planned.4Bring Total from A - Number of Diagnoses/Tx Optionsinto Final Scoring for Medical Decision Making (PPT slide 75).TOTAL
92 Diagnostic Procedure(s) Ordered Management Options Selected Medical Decision Making B. Risk of Complications +/or Morbidity or Mortality Next 4 slides describe level of risk: minimal, low, moderate, high. Final score is the highest component marked.MINALDiagnostic Procedure(s) OrderedManagement Options SelectedOne self-limited or minor problem, e.g. cold, insect bite, tinea corporis.Laboratory tests requiring venipunctureChest x-raysEKG/EEGUrinalysisUltrasound, e.g. echoKOH prepRestGarglesElastic bandagesSuperficial dressingsMinimal; Low; Moderate; HighContinue with coding audit cheat sheet page 2 – Handout 2 - look at Section I on back of coding audit sheet – level 4 (99214) – second boldeditem: “Acute illness with systemic symptoms” Let’s say a Child comes in with fever and says he feels ill = this is a child with an acute illness with systemic symptoms and has the potential of a level 4 exam. An asthmatic with wheezing – level 4 potential.How many of you bill asthmatics as a level 3 because you don’t spend that much time with the patient. Most asthmatics with symptoms will be a level 4. (hard to get have a level 5, but not impossible. Let’s say our patient is a level 4 for management of problem – section I. Now look at section II – diagnostic procedure.
93 Medical Decision Making B Medical Decision Making B. Risk of Complications +/or Morbidity or MortalityLOWPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options SelectedTwo or more self-limited or minor problemsOne stable chronic illness, e.g. well controlled hypertension, non-insulin dependent diabetes, cataract, benign prostatic hyperplasiaAcute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprainPhysiologic tests not under stress, e.g. pulmonary function testsNon-cardiovascular imaging studies with contrast, e.g. barium enemaSuperficial needle biopsiesClinical laboratory tests requiring arterial punctureSkin biopsiesOver the counter drugsMinor surgery with no identified risk factorsPhysical therapyOccupational therapyIV fluids without additivesMinimal; Low; Moderate; HighContinue with coding audit cheat sheet page 2 – Handout 2 - look at Section I on back of coding audit sheet – level 4 (99214) – second boldeditem: “Acute illness with systemic symptoms” Let’s say a Child comes in with fever and says he feels ill = this is a child with an acute illness with systemic symptoms and has the potential of a level 4 exam. An asthmatic with wheezing – level 4 potential.How many of you bill asthmatics as a level 3 because you don’t spend that much time with the patient. Most asthmatics with symptoms will be a level 4. (hard to get have a level 5, but not impossible. Let’s say our patient is a level 4 for management of problem – section I. Now look at section II – diagnostic procedure.
94 Medical Decision Making B Medical Decision Making B. Risk of Complications +/or Morbidity or MortalityMODERATPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options SelectedOne or more chronic illnesses with mild exacerbation, progress, or side effects of treatmentTwo or more stable chronic illnessesUndiagnosed new problem with uncertain prognosis, e.g. lump in breastAcute illness with systemic symptoms, e.g. pyelonephritis, pneumonitis, colitisAcute complicated injury, e.g. head injury with brief loss of consciousnessPhysiologic tests under stress, e.g. cardiac stress test, fetal contraction stress testDiagnostic endoscopies with no identified risk factorsDeep needle or incisional biopsyMinor surgery with identified risk factorsElective major surgery (open, percutaneous or endoscopic) with no identified risk factorsPrescription drug managementIV fluids with additivesClosed treatment of fracture or dislocation without manipulationMinimal; Low; Moderate; HighContinue with coding audit cheat sheet page 2 – Handout 2 - look at Section I on back of coding audit sheet – level 4 (99214) – second boldeditem: “Acute illness with systemic symptoms” Let’s say a Child comes in with fever and says he feels ill = this is a child with an acute illness with systemic symptoms and has the potential of a level 4 exam. An asthmatic with wheezing – level 4 potential.How many of you bill asthmatics as a level 3 because you don’t spend that much time with the patient. Most asthmatics with symptoms will be a level 4. (hard to get have a level 5, but not impossible. Let’s say our patient is a level 4 for management of problem – section I. Now look at section II – diagnostic procedure.
95 Medical Decision Making B Medical Decision Making B. Risk of Complications +/or Morbidity or MortalityHIGPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options SelectedOne or more chronic illnesses with severe exacerbation, progression, or side effects of txAcute or chronic illnesses or injuries that may pose a threat to life or bodily function(e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, sent to ER, eminent delivery)Cardiovascular imaging studies with contrast with identified risk factorsDiagnostic endoscopies with identified risk factorsDiscographyElective major surgery (open, percutaneous or endoscopic) with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug therapy requiring intensive monitoring for toxicityMinimal; Low; Moderate; HighContinue with coding audit cheat sheet page 2 – Handout 2 - look at Section I on back of coding audit sheet – level 4 (99214) – second boldeditem: “Acute illness with systemic symptoms” Let’s say a Child comes in with fever and says he feels ill = this is a child with an acute illness with systemic symptoms and has the potential of a level 4 exam. An asthmatic with wheezing – level 4 potential.How many of you bill asthmatics as a level 3 because you don’t spend that much time with the patient. Most asthmatics with symptoms will be a level 4. (hard to get have a level 5, but not impossible. Let’s say our patient is a level 4 for management of problem – section I. Now look at section II – diagnostic procedure.Final score is the highest component marked.Bring the Risk Level from “B - Risk of Complications +/or Morbidity or Mortality”into final scoring for Medical Decision Making (see PPT slide 75).
96 Medical Decision-Making C Medical Decision-Making C. Amount +/or Complexity of Data to be ReviewedData to be ReviewedPointsReview +/or order of clinical lab tests1Review +/or order of tests in the radiology section of CPTReview +/or order of tests in the medicine section of CPTDiscussion of test results with performing providerDecision to obtain old records +/or obtain history from someone other than patientReview + summarization of old records +/or obtaining history from someone other than patient +/or discussion of case with another health care provider2Independent visualization of image, tracing or specimen itself (not simply review of report)Bring Total from C - Amount +/or Complexity of Data to be Reviewed into Final Scoring for Medical Decision Making (see PPT slide 75) TOTAL
97 Medical Decision Making Scoring Tool Level of Decision MakingStraight-forwardLowComplexityModerate ComplexityHighA: Number of diagnoses or treatment optionsMinimal(<1)Limited(2)Multiple(3)Extensive(>4)B: Risk for Complications +/or Morbidity or MortalityModerateC: Amount +/or Complexity of Dataor LowSame as Audit Tool*To score medical decision making, two of the three elementsin the table above must be met or exceeded.
98 Selecting the Correct Office Visit Level for a “New” Patient * Requires 3 components in one column be met or exceededto select that CPT code level.HistoryPFEPFDCExaminationComplexity of Medical Decision-MakingSFLMHAverage Time(Minutes)10”20”30”45”60”Level1CPT 992012CPT 992023CPT 992034CPT 992045CPT 99205Time vs. 3 Components Move time below…
99 Selecting the Correct Office Visit Level for an “Established” Patient * Requires 2 components in one column be met or exceededto select that CPT code level.HistoryMinimal problem thatmay not requirepresence of medical provider.PFEPFDCExaminationComplexity of Medical Decision-MakingSFLMHAverage Time(Minutes)5”10”15”25”40”Level1CPT 992112CPT 992123CPT 992134CPT 992145CPT 99215
101 Supplemental CodesUnusual time or location use E/M or procedure code plus special services code ( ).Critical Care Services ( ) unstable critically ill or unstable critically injured requiring constant attendance of the provider provided in any location.Prolonged Services Codes ( ) coded with E/M codes – subtract amount of time associated with the E/M Code
102 Coding TipsLink procedures with justifying diagnosis to establish “medical necessity”Avoid “clustering” (i.e. using one or two middle level service codes assuming that it will all even out in the end).
103 DocumentationIf it isn’t documented, it wasn’t done – from an audit perspective.The medical record should be complete and legible.The documentation of each patient encounter should include:Date of encounterReason for encounter (chief complaint) and relevant historyPhysical examination findings and screening/diagnostic test resultsAn assessment, clinical impression or diagnosisA plan of careSignature and credential of clinicianS-O-A-P notes help assure complete documentationDocument the elements that justify the level of E/M key components.The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred.
104 Documentation (continued) Health risk factors should be identified and addressed.The patient’s progress, response to / changes in treatment, and revision of diagnosis should be documented.Document to whom referrals are made and outcomes from previous referrals.Include orders for lab work, x-rays or tests; returned reports should be initialed / dated; document review of reports in progress note.CPT and ICD-9-CM codes reported on the health insurance claim form or patient billing statement should be supported by the documentation in the billing record.