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POH/DMC UROLOGY Grand Round Conference Presented by: Spectrum Billing Technologies, LLC.

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Presentation on theme: "POH/DMC UROLOGY Grand Round Conference Presented by: Spectrum Billing Technologies, LLC."— Presentation transcript:

1 POH/DMC UROLOGY Grand Round Conference Presented by: Spectrum Billing Technologies, LLC

2 Coding & Compliance

3 Teaching Hospital A hospital engaged in an approved Graduate Medical Education (GME) residency program in Medicine, Osteopathy, Dentistry, or Podiatry

4 Teaching Physician Teaching physician is a physician (other than a resident) who involves residents in the care of his or her patients

5 Payment Payments under the physician fee schedule are made if the services are furnished by a physician, jointly by a physician & resident, or by a resident in the presence of a teaching physician

6 E&M Payment Under the Physician Fee Schedule A personal notation must be made by the teaching physician demonstrating his/her presence in the history, exam, and medical decision making with a brief, summary comment related to the resident’s entry to confirm or revise key elements

7 Surgical Procedure Payment Under the Physician Fee Schedule In the case of a surgical procedure, the teaching physician must be present during all critical portions of the procedure and must be immediately available to furnish services during the entire procedure

8 Minor Procedure Payment Under the Physician Fee Schedule The teaching physician must be PRESENT for the entire procedure

9 “Billing Codes” CPT CODE Describes WHAT was done ICD9 CODE Describes WHY it was done

10 CPT Code Defined CPT codes describe medical procedures and services All CPT codes are 5 digit codes Each CPT code represents the universal definition of a service or procedure

11 CPT, Continued CPT coding controls the health care provider’s reimbursement Accurate CPT coding provides effective communication of medical services among healthcare entities

12 CPT/ICD9 Relationship The ICD9 code must provide an indication of MEDICAL NECESSITY for the service (CPT code) provided Insurance companies “link” each type of service with specific diagnosis codes that support the “reason” for the service

13 Evaluation & Management Outpatient E&M services require a differentiation for new vs established patients Code selection will affect the provider’s reimbursement….new patient codes are paid a higher rate

14 New vs Established Patient A new patient is one who has not received any professional services from the physician (or specialty group) within the past 3 years An established patient is one who has received professional services from the physician (or group) within the past 3 years

15 New Patient Coding New patient outpatient Evaluation & Management codes are 99201, 99202, 99203, 99204, and 99205 The “level” of service is determined by 3 Key Components of the visit…History, Exam, Medical Decision Making

16 Established Patient Coding Established patient Outpatient E& M Codes are 99211 (Nurse Visit), 99212, 99213, 99214, and 99215 The “level” of service is determined by 3 Key Components of the visit…History, Exam, Medical Decision Making

17 Chief Complaint A concise statement describing the symptom, problem, conditions, diagnosis or other factor that is the reason for the encounter, usually stated in the patients words…..

18 Past Family Social History A review of medical events in the patient’s family that includes information about parent, sibling, children health history Specific diseases related to problems identified in the chief complaint

19 PFSH, cont. Diseases of family members which may be hereditary or place the patient at risk Patient history, surgery, obstetrics, illness, injury, immunization, etc. Tobacco, alcohol, drugs, violence, diet

20 History of Present Illness A chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present (location, quality, severity, timing, context, modifying factors and associated signs and symptoms).

21 Review of Systems An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing, or has experienced….i.e. weight gain, abnormal bleeding, masses, etc.

22 Examination General multi-system exam or a single organ system exam may be performed by any physician regardless of specialty The content of the exam is selected based on clinical judgement, patient history, and the nature of the presenting problem

23 Medical Decision Making Diagnosis AND/OR management options Amount/Complexity Data Risk of Complications

24 Counseling – Coordination of Care When counseling/coordination of care dominates more than 50% of the visit….time may be considered the key or controlling factor for a particular level of E/M service.

25 Counseling Counseling is a discussion concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis

26 Counseling, cont. Risks & Benefits of management options Instructions for treatment and/or follow-up Importance of compliance with treatment options

27 Counseling, cont. Risk factor reduction Patient education

28 Time 99201 – 10 min 99202 – 20 min 99203 – 30 min 99204 – 45 min 99205 – 60 min 99211 – Nurse Visit 99212 – 10 min 99213 – 15 min 99214 – 25 min 99215 – 40 min


30 Consultation Coding Outpatient consultation codes are 99241, 99242, 99243, 99244, and 99245. Inpatient consultation codes are 99251, 99252, 99253, 99254, and 99255

31 Consultations The request and need for the consultation must be documented in the patient’s medical record All services provided and the resulting “advice or opinion” must be provided in writing to the requesting physician

32 Consultations, Cont. Consultation services are reimbursed at a higher rate than the Out-Patient or In-Patient E & M Services

33 Initial Hospital Care Only one physician may submit an initial hospital care code for the same patient (99221, 99222, 99223) Co-Admitting physicians must decide who will bill initial hospital care If both do, the first claim received will be paid, with the second rejected

34 Subsequent Hospital Care Hospital visit codes are used to report DAILY services (99231, 99232, 99233) Multiple visits on the same day, by the same physician, must be reported as 1 visit with a higher level code incorporating both visits

35 Concurrent Hospital Care Providing similar hospital visits to the same multiple physicians.. on the same day..with the same diagnosis..will likely be denied Avoid using the “admitting” diagnosis Code for the SPECIFIC reason YOUR SPECIALTY saw the patient

36 Hospital “Floor Time” Hospital Services (Initial & Subsequent) include the time the physician is present at the patient’s bedside and on the unit to include time spent reviewing the chart, writing notes, exam time, and coordination of the patient’s care

37 Hospital Discharge 99238 - Hospital discharge day management; 30 minutes or less 99239 – Hospital discharge day management; more than 30 minutes

38 ICD9 Coding Defined The “reason” for procedures, services, and supplies are converted into ICD9 Diagnosis Codes Codes identify diagnosis, symptoms, conditions, problems, complaints or other reasons for service

39 Suspected Conditions If a diagnosis is questionable, probable, likely, or rule out code the signs, symptoms, or complaints Avoid reporting a diagnosis code that is not proven…use signs, symptoms, complaints

40 Complications Complications are responsible for many procedures therefore the complication should be coded For example: 998.5 Postoperative Infection 997.3 Respiratory Complications

41 Questions ???

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