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Getting It Right the First Time Coding and Documentation - 2013 Steven Allen Adams.

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Presentation on theme: "Getting It Right the First Time Coding and Documentation - 2013 Steven Allen Adams."— Presentation transcript:

1 Getting It Right the First Time Coding and Documentation Steven Allen Adams

2 Discussion Points Incident ToIncident To E and M Coding for:E and M Coding for: ­Office Visits ­Pre-operative Consultations ModifiersModifiers ­E/M Only ­Surgery Only ­Global Periods Preventive ServicesPreventive Services Transitional Care ManagementTransitional Care Management

3 Incident To

4 Incident To Billing Using MD # 4 standard criteria for Incident To: 1.Physician must be in office 2.Must be an established patient 3.Must not change anything from previous plan of care 4.Doctor should see patient every 3 rd or 4 th visit (shows active participation)

5 E&M Coding

6 Code Selection Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

7 A Word on “Cloning” Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This “cloned documentation” does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.

8 Office – Outpatient Services

9 Outpatient Visit New / Consults “Requires All Three Key Elements”

10 New/Consultation Patient Visits (3 out of 3) CodeMinutesHistoryExaminationDecision-Making Problem Focused  CC  1HPI Problem Focused 1995 –(1) 1997 – (1 check) Straightforward  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Exp. Problem Focused  CC  1 HPI  1 ROS Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Straightforward  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) Low  Diagnosis – Limited  Data – Limited  Risk – Low OTC, Short-term Meds, Minor Surgery Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate Long term Rx or Major Surgery Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High  Diagnosis – Extensive  Data – Extensive  Risk – High

11 New Patient Definition A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

12 New Patients – Think: – No treatment – Short term meds, OTC, minor surgery – Long term meds, major surgery – Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

13 Initial Visits

14 Importance of History Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements. Staff can do the past medical history, family history, social history but we expect the provider to do the chief complaint in the history of present illness

15 Unable To Obtain History T he physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

16 Normal and Negative For the examine and the review of system(s) related to the presenting problem - do not describe as "normal" or "negative."

17 Other Issues Extended HPI – 4 HPI or Status of 3+ chronic or inactive conditions. Complete ROS (lots of questions on the ROS.

18 1995 – Comprehensive (8) 1.Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. 2.Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3.ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4.Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5.Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6.Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. 7.Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8.Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9.GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

19 What Doesn’t Count (8) Head Neck Thyroid Abdomen Extremities Back Under the 1995 Guidelines CMS and the AMA want you to examine “ORGAN SYSTEMS” and not body areas with regard to any code with the number (8) in the exam criteria

20 Expanded vs. Extended The difference is not the number of systems examined. Two to seven systems are required for both examinations. The difference is the detail in which the examined systems are described.

21 1995 – Detailed 4-7 (4x4) 1.Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. 2.Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3.ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4.Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5.Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6.Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. 7.Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8.Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9.GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

22 1997 “Bullet Guidelines” Allow you to document systems and areas, however you have to be very specific about what you document about those systems and areas. Most EMRs are based on the 1997 guidelines but are not compliant

23 1997 Guidelines - Correct EYES: [ ] Sclera white, conjunctive clear. Lids are without lag. [ ] PERRLA. ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink / symmetric. This would be 5 bullets and compliant

24 1997 Guidelines – Not Correct EYES: [ ] Sclera white, [ ]conjunctive clear. Lids are without lag. [ ] PERRLA. ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. [ ] Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink [ ] Lips symmetric. This would be 8 bullets and not compliant

25 What To Do I’ll have a copy of those guidelines posted on my web site and I’ll give you a link on medicalofficeblog.com Make sure that you are only getting credit for what the government says you get credit for documenting. THIS IS A CRITICAL COMPONENT OF YOUR EMR COMPLIANCE

26 New Patients – Think: – No treatment – Short term meds, OTC, minor surgery – Long term meds, major surgery – Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

27 Outpatient Visit Established Patient “Requires Two of Three Key Elements”

28 Established Patients – Think: – One stable condition – Two stable or one unstable problem 99214: ­3 chronic stable on meds ­2 unstable on meds ­1 stable and one unstable on meds – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

29 Established Visits

30 Established Patient Visits (2 out of 3) 99211N/A Problem Focused  CC  1HPI Problem Focused 1995 –(1) 1997 – (1 check) Straightforward  Diagnosis – Minimal 1  Data – Minimal or None 1  Risk – Minimal 1 1 stable problem Exp. Problem Focused  CC  1 HPI  1 ROS Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Low  Diagnosis – Limited 2  Data – Limited 2  Risk – Low 2 2 stable problems 1 unstable problem Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) Moderate  Diagnosis – Multiple 3  Data – Moderate 3  Risk – Moderate 3 3 stable problems on meds 1 stable and 1 unstable on meds 2 unstable problems on meds New problem requiring major surg Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High  Diagnosis – Extensive 4  Data – Extensive 4  Risk – High 4 Very sick patient with extensive data review and high risk

31 Counseling Dominated 3 standard criteria for time: 1.Total Face-to-Face time of provider 2.That more than 50% was counseling 3.Topics you discussed “If the level of care is being based on time spent with the patient for counseling/coordination of care documentation should support the time for the visit and the documentation must support in sufficient detail the nature of the counseling”

32 Signature Requirements Make sure you properly SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have the provider’s signature. If the provider is initialing this documentation he/she must also print their name by the initials or circle the typed name on an office form. This lets the reviewer clearly see that who documented the medical record.

33 Established Patients – Think: – One stable condition – Two stable or one unstable problem 99214: ­3 chronic stable on meds ­2 unstable on meds ­1 stable and one unstable on meds – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

34 Hospital – Inpatient / Outpatient

35 Initial Hospital Visits 3 out of 3 CodeMinutesHistoryExaminationDecision-Making Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) Straightforward / Low  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Comprehensive  CC  4 HPI or status of 3 chronic conditions 10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High  Diagnosis – Extensive  Data – Extensive  Risk – High Subsequent Hospital Visits 2 out of 3 Problem Focused  CC  1HPI Problem Focused 1995 –(1) 1997 – (1 check) Straightforward / Low  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Exp. Problem Focused  CC  1 HPI  1 ROS Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) High  Diagnosis – Extensive  Data – Extensive  Risk – High Hospital Discharge Hospital Discharge 99239> 30 Hospital Discharge > 30 minutes – {Must document time} Definitions 99221Admission – Low Risk 99222Admission – Moderate Risk 99223Admission – High Risk 99231Patient is responding well 99232Pt is responding inadequately to therapy / developed a minor complication 99233Pt is unstable or has developed a significant complication / significant new problem

36 Per Change Request 5794, the Hospital Discharge Day Management Service (CPT code or 99239) is a face-to- face evaluation and management (E/M) service with the patient and his/her attending physician. Therefore, the time must be spent with the patient. Time

37 Observation Coding

38 Observation/Hospital Discharge Same Day - 3 out of 3 CodeMinutesHistoryExaminationDecision-Making Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) Straightforward / Low  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High  Diagnosis – Extensive  Data – Extensive  Risk – High

39 Observation - 3 out of 3 (first day of a multiple day observation service) Detailed / Comprehensive  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) Straightforward / Low  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal 99218N/A Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate 99219N/A Comprehensive  CC  4 HPI or status of 3 chronic conditions  10 ROS  Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High  Diagnosis – Extensive  Data – Extensive  Risk – High 99220N/A

40 Subsequent Observation Care Visits - 2 out of 3 (day(s) after first till day before discharge) Problem Focused  CC  1HPI Problem Focused 1995 –(1) 1997 – (1 check) Straightforward / Low  Diagnosis – Minimal  Data – Minimal or None  Risk – Minimal Exp. Problem Focused  CC  1 HPI  1 ROS Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Moderate  Diagnosis – Multiple  Data – Moderate  Risk – Moderate Detailed  CC  4 HPI or status of 3 chronic conditions  2 ROS  Medical or Family or Social History Detailed 1995 – (4-7 – need 4x4) 1997 – (12 checks) High  Diagnosis – Extensive  Data – Extensive  Risk – High Observation Discharge (final day of observation) 99217N/A Observation care discharge on date other than initial observation day

41 The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making documentation in the medical record shall include: 1.Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours; 2.Documentation identifying the billing physician was present and personally performed the services; and 3.Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.

42 When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range – 99220, shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario.

43 In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

44 Modifiers

45 Global Period 0-10 days = minor (-25 on E&M) 90 days = major actually 92 days (-57 on E&M) MMM = maternity codes XXX = global concept doesn’t apply (x-ray/lab) YYY = up to carrier (unlisted codes) ZZZ = always included in global of another service (add on codes)

46 E&M Only Modifiers 24 – Unrelated E&M24 – Unrelated E&M 25 – E&M and minor surgery same day25 – E&M and minor surgery same day 57 – E&M day before or day of major surgery57 – E&M day before or day of major surgery Use of the 25 modifier means the procedure note is separate from the E&M note

47 Surgery Only Modifiers 58 – Anticipated at time of initial procedure58 – Anticipated at time of initial procedure 78 – Related to initial procedure78 – Related to initial procedure 79 – Unrelated to initial procedure79 – Unrelated to initial procedure Use of the 78 modifier means the second procedure will be reduced

48 The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. His documentation states, "Pre-op dx: Painful left ovarian cyst. Procedure in order performed (two auxiliary ports): 1. Diagnostic Laparoscopy – (8.38 RVU) 2. Left ovarian cystectomy – (19 RVU) 3. Sharp dissection of adhesions from sigmoid to left adnexa – (17.94 RVU) A , 58660, B C , , D , , y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: A , B C , D , y/o male playing football at a family reunion when he felt his leg “snap.” The patient presents to emergency room and is diagnosed with a closed Tib/Fib fracture of the right leg. Pt is evaluated in the ER by an orthopedic surgeon at the request of the ER attending and fracture is set by Orthopedic physician: A B , C , D Patient presents to the Dermatologist with a “benign” lesion on their right leg. The lesion is excised (11402) and layered closure is performed (12031) on February 1 st. One week later the patient returns to have their sutures removed. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: A , B ,25, C D , While in the global period of the Tib/Fib fracture (which was repaired by the orthopedic surgeon), the patient presents to his primary care doctor for evaluation of lower back pain: A B C D y/o woman present to OBGYN for annual exam. She is not at high risk for cervical cancer and has had her covered breast and pelvic examination performed last year. You had the patient sign an ABN prior to procedure being furnished. During this examination, the physician also addresses her HTN, OA, DM and CHF. Her physician performs an office visit, pap smear and pelvic/breast examination. Her secondary insurance company does cover preventive services: A B GV-Q5 C D Q6 A child was admitted for an obstructed airway. The physician performed an immediate diagnostic flexible bronchocospy (31622 – 4.02 RVU). Two transbronchial lung biopsies of abnormal tissue were taken. One from the superior lobe (31628 – 5.28 RVU) and another from the middle lobe ( – 1.52 RVU). In addition, a small tiny “Lego” head was found lodged in the inferior lobe and was removed (31635 – 5.34 RVU). Select the professional CPT code(s) for this procedure: A , 31628, B , , C , , D , , A diabetic patient undergoes surgery for removal of gangrenous toe (28825). During the postoperative period, it becomes necessary to amputate the entire foot (28800). A B C D A patient underwent colonoscopy with multiple biopsies (45380) earlier in the day. Four hours later, the patient returns to the office with rectal bleeding and is taken back to the endoscopy suite to control bleeding from the biopsy sites (45382). Code for these procedures: A , B C D , Steve did some auditing work one-day for a GI doctor in Albany. The audit was less than favorable for this respected physician in the community. Shortly after the audit, Steve found himself eating dinner in Albany at one of his favorite Italian restaurants. At some point in the meal, Steve began to vomit profusely and was rushed to a local hospital. The GI doctor on call that night was, you guessed it, our respected GI doctor who had failed so miserably on his audit. Upon recognizing Steve, the doctor immediately orders both a diagnostic upper GI and diagnostic lower GI. To make matters worse, our GI doctor did these procedures at separate sessions. After these procedures, Steve never found poor documentation in that physician’s notes again. They both lived happily ever after. A , B , C , D , A 56 y/o morbidly obese female is in need of a Total Abdominal Hysterectomy (TAH) (58150). Two surgeons from the same group work perform this surgery. How would the primary surgeon – surgeon A bill as well as the assistant surgeon B. A. Surgeon A – 58150, can’t bill assist for Surgeon B because in they are in same group B. Surgeon A – // Surgeon B C. Both Surgeons A and B bill D. Surgeon A – // Surgeon B bills While on a skiing vacation in Colorado, Steve fractures his femur and requires emergency surgery to treat this fracture (27507). Ten days later Steve returns home and has four follow-up visits by his local orthopedic surgeon. How should his first visit be coded by the Orthopedic surgeon in Steve’s hometown for post-op management? A B quantity of 80 C quantity of 10 D Dr. Brooks provides the new occult blood test that uses an immunoassay determination (82274) instead of a guaiac determination (82270). Over the last three months the code is being denied and not covered. What is the correct way to bill for this service? A B QW C D Dr. Clark is in an county designated by his carrier to be a HPSA. He provides a office visit and EKG. How would he code for this to ensure he receives his 10% HPSA bonus. A , B AQ, AQ C AR, AR D , y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: A , B C , D , E&M and Minor Surgery

49 The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. His documentation states, "Pre-op dx: Painful left ovarian cyst. Procedure in order performed (two auxiliary ports): 1. Diagnostic Laparoscopy – (8.38 RVU) 2. Left ovarian cystectomy – (19 RVU) 3. Sharp dissection of adhesions from sigmoid to left adnexa – (17.94 RVU) A , 58660, B C , , D , , y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: A , B C , D , y/o male playing football at a family reunion when he felt his leg “snap.” The patient presents to emergency room and is diagnosed with a closed Tib/Fib fracture of the right leg. Pt is evaluated in the ER by an orthopedic surgeon at the request of the ER attending and fracture is set by Orthopedic physician: A B , C , D Patient presents to the Dermatologist with a “benign” lesion on their right leg. The lesion is excised (11402) and layered closure is performed (12031) on February 1 st. One week later the patient returns to have their sutures removed. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: A , B ,25, C D , While in the global period of the Tib/Fib fracture (which was repaired by the orthopedic surgeon), the patient presents to his primary care doctor for evaluation of lower back pain: A B C D y/o woman present to OBGYN for annual exam. She is not at high risk for cervical cancer and has had her covered breast and pelvic examination performed last year. You had the patient sign an ABN prior to procedure being furnished. During this examination, the physician also addresses her HTN, OA, DM and CHF. Her physician performs an office visit, pap smear and pelvic/breast examination. Her secondary insurance company does cover preventive services: A B GV-Q5 C D Q6 A child was admitted for an obstructed airway. The physician performed an immediate diagnostic flexible bronchocospy (31622 – 4.02 RVU). Two transbronchial lung biopsies of abnormal tissue were taken. One from the superior lobe (31628 – 5.28 RVU) and another from the middle lobe ( – 1.52 RVU). In addition, a small tiny “Lego” head was found lodged in the inferior lobe and was removed (31635 – 5.34 RVU). Select the professional CPT code(s) for this procedure: A , 31628, B , , C , , D , , A diabetic patient undergoes surgery for removal of gangrenous toe (28825). During the postoperative period, it becomes necessary to amputate the entire foot (28800). A B C D A patient underwent colonoscopy with multiple biopsies (45380) earlier in the day. Four hours later, the patient returns to the office with rectal bleeding and is taken back to the endoscopy suite to control bleeding from the biopsy sites (45382). Code for these procedures: A , B C D , Steve did some auditing work one-day for a GI doctor in Albany. The audit was less than favorable for this respected physician in the community. Shortly after the audit, Steve found himself eating dinner in Albany at one of his favorite Italian restaurants. At some point in the meal, Steve began to vomit profusely and was rushed to a local hospital. The GI doctor on call that night was, you guessed it, our respected GI doctor who had failed so miserably on his audit. Upon recognizing Steve, the doctor immediately orders both a diagnostic upper GI and diagnostic lower GI. To make matters worse, our GI doctor did these procedures at separate sessions. After these procedures, Steve never found poor documentation in that physician’s notes again. They both lived happily ever after. A , B , C , D , A 56 y/o morbidly obese female is in need of a Total Abdominal Hysterectomy (TAH) (58150). Two surgeons from the same group work perform this surgery. How would the primary surgeon – surgeon A bill as well as the assistant surgeon B. A. Surgeon A – 58150, can’t bill assist for Surgeon B because in they are in same group B. Surgeon A – // Surgeon B C. Both Surgeons A and B bill D. Surgeon A – // Surgeon B bills While on a skiing vacation in Colorado, Steve fractures his femur and requires emergency surgery to treat this fracture (27507). Ten days later Steve returns home and has four follow-up visits by his local orthopedic surgeon. How should his first visit be coded by the Orthopedic surgeon in Steve’s hometown for post-op management? A B quantity of 80 C quantity of 10 D Dr. Brooks provides the new occult blood test that uses an immunoassay determination (82274) instead of a guaiac determination (82270). Over the last three months the code is being denied and not covered. What is the correct way to bill for this service? A B QW C D Dr. Clark is in an county designated by his carrier to be a HPSA. He provides a office visit and EKG. How would he code for this to ensure he receives his 10% HPSA bonus. A , B AQ, AQ C AR, AR D , One week later the patient returns for follow-up visit for his elevated BP and to have the skin tag sites examined. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and changes the BP medicine and then destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: A , B ,25, C D , E&M in Global 6

50 Preventive Medicine Services

51 Prevention Services CMS is proposing to develop separate Level II HCPCS codes for the first annual wellness visit, to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for the subsequent annual wellness visits, to be paid at the rate of a level 4 office visit for an established patient.

52 IPPE- Welcome to Medicare 1.Review Medical and Social History. 2.Review Risk Factors for Depression and Mood Disorders. 3.Review Functional Ability and Level of Safety. 4.Height, Weight, BP, VA, BMI. 5.End-of-life Planning If Needed 6.Education, Counseling and Referrals Based on Above 7.Education, Counseling, and Referrals for Other Listed Services

53 New AWV Codes G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit); and G0439 (Annual wellness visit; includes a personalized prevention plan of service (PPPS),subsequent visit). We note that practitioners furnishing a preventive medicine E/M service that does not meet the requirements for the IPPE or the AWV would continue to report one of the preventive medicine E/M services CPT codes in the range of through as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare."

54 In the CY 2011 PFS final rule with comment period (75 FR 73411), we stated “that when the Health Risk Assessment is incorporated in the AWV, we will reevaluate the values for HCPCS codes G0438 and G0439”. As discussed in the CY 2011 PFS final rule with comment period, the services described by CPT codes and already include ‘preventive assessment' forms. For CY 2012, we believe that the current payment crosswalk for HCPCS codes G0438 and G0439 continue to be most accurately equivalent to a level 4 E/M new or established patient visit; and therefore, we are proposing to continue to crosswalk HCPCS codes G0438 and G0439 to CPT codes and 99214, respectively.75 FR 73411

55 AWV - Initial 1.Health Risk Assessment 2.Establishment of an individual's medical and family history. 3.Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual. 4.Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. 5.Detection of any cognitive impairment that the individual may have. 6.Review of the individual's potential (risk factors) for depression, Review of the individual's functional ability and level of safety, based on direct observation. 7.Review of the individual's functional ability and level of safety, based on direct observation 8.Establishment of the following: ++ A written screening schedule, such as a checklist, for the next 5 to 10 years ++ A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended. 8.Furnishing of personalized health advice to the individual and a referral, as appropriate. 9.Any other element determined appropriate through the National Coverage Determination process.

56 AWV - Subsequent 1.Health Risk Assessment 2.An update of the individual's medical and family history. 3.An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing personalized prevention plan services. 4.Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. 5.Detection of any cognitive impairment, as that term is defined in this section, that the individual may have. 6.An update to both of the following: ++ The written screening schedule for the individual as that schedule was developed at the first AWV providing personalized prevention plan services. CMS-1503-FC The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV providing personalized prevention plan services. 6. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined in paragraph (a) of this section. 7.Any other element determined through the NCD process.

57 Has Pt. Had Medicare for More than 12 Months Has Pt. Received An Initial AWV From Medicare G0438 YesG0402No Yes No G0439

58 Has Pt. Had Medicare for More than 12 Months Has Pt. Received An Initial AWV From Medicare G0438 YesG0402No Yes No G0439

59 Has Pt. Had Medicare for More than 12 Months Has Pt. Received An Initial AWV From Medicare G0438 YesG0402No Yes No G0439

60 Has Pt. Had Medicare for More than 12 Months Has Pt. Received An Initial AWV From Medicare G0438 YesG0402No Yes No G0439

61 Breast / Pelvic Exam The HCPCS Code: G0101 – Pelvic and Breast Exam The Diagnosis Codes V72.31 Routine gynecological exam V76.47 Screening for neoplasm of the vagina V76.49 Screening of woman without a cervix V76.2 Screening for neoplasm of cervix V15.89* - Every Year Presenting health hazards

62 Four Questions C ERVICAL C ANCER H IGH R ISK S URVEY Was your first sexual activity prior to the age of 16?  Yes  No Have you had more than 5 sexual partners?  Yes  No Do you have a history of sexually transmitted disease (including HIV) infection?  Yes  No Have you had fewer than 3 negative pap smears within the previous seven years?  Yes  No

63 Exam Required Female G/U: (7 of the following 11)  Breasts symmetrical. No masses, lumps, tenderness, dimpling or nipple discharge.  Rectal exam exhibits even sphincter tone, no hemorrhoids or masses. Pelvic  No external lesions. Normal hair distribution.  Urethral meatus pink, no lesions or discharge.  Urethra intact, no tenderness, masses, inflammation or discharge.  Bladder without tenderness or masses, no incontinence.  Vaginal mucosa moist and pink, without lesions or discharge.  Cervix pink, no lesions, odor, or discharge.  Uterus midline, non-tender, firm and smooth.  No adnexal masses, nodules or tenderness.  Anus and perineum intact. ___ No lesions, rashes, fissures, fistulas or external hemorrhoids. Wet Prep __________________ Hemoccult Pos. Neg.

64 Obtain Pap Smear The HCPCS Code: Q Obtaining screen pap smear The Diagnosis Codes V72.31 Routine gynecological exam V76.47 Screening for neoplasm of the vagina V76.49 Screening of woman without a cervix V76.2 Screening for neoplasm of cervix V15.89* - Every Year Presenting health hazards

65 Tobacco Cessation Codes The CPT Codes: 99406: Smoking and tobacco cessation counseling; intermediate, greater than 3 minutes, up to 10 minutes, 99407: Smoking and tobacco cessation counseling; intensive, greater than 10 minutes, The Diagnosis Codes Medical dx of the patient at the time of the visit the tobacco is affecting If used with E/M, don’t forget modifier 25

66 New Tobacco Cessation Codes The HCPCS Codes: G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, The Diagnosis Codes ICD-9 code (non-dependent tobacco use disorder), or ICD-9 code V15.82 (history of tobacco use).

67 Home Health Certification The HCPCs Codes: G0179 – Re-certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care … G Certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care …

68 Content of the Physician's Certification The home health services are because the individual is confined to his/her home and needs intermittent skilled nursing care (other than solely for venipuncture for the purposes of obtaining a blood sample), physical therapy and/or speech-language pathology services, or continues to need occupational therapy; A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; (next slide) The services are or were furnished while the individual was under the care of a physician. The need for skilled oversight of unskilled services (management and evaluation of the care plan). The physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification or as a signed addendum to the certification and recertification. Home Health Certification

69 Content of the Plan of Care Signed by Physician The patient's mental status; The types of services, supplies, and equipment required; The frequency of the visits to be made; Prognosis; Rehabilitation potential; Functional limitations; Activities permitted; Nutritional requirements; All medications and treatments; Safety measures to protect against injury; Instructions for timely discharge or referral; and Any additional items the HHA or physicians choose to include. The physician who signs the plan of care must be the same physician to sign the physician certification. Home Health Certification

70 Time Frame Requirements The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care. Encounter Documentation Requirements The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services. Home Health Certification

71 Care Plan Oversight The HCPCS Codes: G0181 – Supervision of patient receiving Medicare- covered home health agency requiring complex multidisciplinary care…30 minutes or more G Supervision of patient receiving Medicare- approved hospice care requiring complex multidisciplinary care…30 minutes or more

72 CMS and TCM Transitional Care Management Services with the following required elements : ­Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. ­Medical decision making of at least moderate complexity during the service period. ­Face-to-face visit, within 14 calendar days of discharge Transitional Care Management Services with the following required elements : ­Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. ­Medical decision making of high complexity during the service period. ­Face-to-face visit, within 7 calendar days of discharge.

73 Discussion Points Incident ToIncident To E and M Coding for:E and M Coding for: ­Office Visits ­Pre-operative Consultations ModifiersModifiers ­E/M Only ­Surgery Only ­Global Periods Preventive ServicesPreventive Services Transitional Care ManagementTransitional Care Management

74 Questions?

75 Any Questions Direct: E-Fax: Web: Facebook: facebook.com/kingofcoders


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