Presentation on theme: "CODING and BILLING Am I Being Paid Appropriately?"— Presentation transcript:
1 CODING and BILLING Am I Being Paid Appropriately? Sandra M. Nettina, MSN, CRNPPresident, NPAMNurse Practitioner, Columbia Medical Practice
2 CODING ICD-9 International Classification of Diseases Published by United States GovernmentDiagnoses basedAssign codes to your assessment at the highest level of differentiationCPT Current Procedural TerminologyCopyrighted by American Medical AssociationProcedural rather than disease or disorder
3 Coding (cont.)ICD-9 codes are used to justify medical necessity of a serviceCPT codes are used for billingEvaluation and management codes (E&M) are CPT codes that describe consultations, ER, and office visits
4 Evaluation and Management Codes new and established office visit 99201/99211: 10 min. (new) or 5 min. (est.)Presenting problem is self limiting or minor99202/99212: 20 min. (new) or 10 min. (est.)low to moderate severity99203/99213: 30 min. (new) or 15 min. (est.)moderate severity99204/99214: 45 min. (new) or 25 min. (est).moderate to high severity99205/00215: 60 min. (new) or 40 min. (est.)
5 Other Encounters Outpatient consultation: 99241 to 99245 Inpatient consultation: to 99255Emergency Room: to 99285Initial hospital observation: to 99223Subsequent hospital: to 99233Initial nursing facility: to 99306Subsequent nursing facility: to 99310Domiciliary, Rest home, custodial care
6 BillingUse E&M codes for Outpatient Visits, Consultations (outpatient and inpatient), ER visits Calculated by 7 components Similar process for hospital observation, nursing facility, and home care, but will not be discussed
7 Components determine E&M coding level—must be documented KeyHistoryExamMedical Decision Making(MDM)ContributingCounselingCoordinationNature of Presenting ProblemTime
8 HISTORY Chief Complaint—required for all level of visits History of Present Illness (HPI)—brief or extendedReview of Systems (ROS)—problem focused, extended, completePast, Family, Social History (PFSH)—pertinent or completeHow much information is obtained and documented?
9 CC and HPIChief complaint is required for all level of histories: simple statementHPI elements: OLFQQAAT, OLDCART, PQRSTOnset, location, frequency, duration, quality (character), quantity (severity), aggravating factors, relieving factors (treatments tried), associated factors
10 REVIEW of Systems Constitutional Neurologic Eyes Psychiatric Ears, nose, throatEndocrineCardiac/vascularHeme/lymphRespiratoryAllergy/immunologyGIGUMusculoskeletalIntgumentary/breast
11 Past Medical, Family, and Social History Past illnesses, chronic conditions, surgeries, injuries, hospitalizations, health screening and diagnostic testsMedicationsRelated family historySocial history—tobacco, alcohol, drugs, exercise, diet, work, sexual activity
12 Level of History Type of History CC HPI ROS PFSH Problem Focused RequiredBrief (1-3 elements)Not requiredExpanded problem focusedProblem pertinentDetailedExtended (4+ elements, or status of 3+ chronic conditions)Extended (2-9 systems)Pertinent (1 item from 1 area)ComprehensiveExtendedComplete (10+ systems)Complete (1 item from 2 areas (est.) or 3 areas (new))
13 Level of History (cont.) Complete ROS—10 or more systems or some systems with statement “all other systems negative”Complete PFSH—need 3 for new patients, consultations, hospital observation, initial nursing facility careDetermine the level of history by the column farthest to the left (one poorly documented element can bring the level down).
15 EXAMProblem focusedExpanded problemDetailedCompre-hensiveSingle Organ System1-5 elementsAt least 6elementsAt least 12(eye and psych: 9)All elementsMulti-system Exam1-5 elements in 1 or more systemsAt least 6 elements in 1 or more systemsAt least 6 systems with 2 elements eachAt least 9 systems with 2 elements each
16 Medical Decision Making Number of diagnoses and treatment optionsAmount and complexity of data reviewedRisk of complicationsMorbidity and mortality
17 Number of Diagnoses and Treatment Options Problem StatusPointsSelf limited or minor1Established problem (to examiner): stable or improvedEstablished problem (to examiner): worsening2New problem (to examiner): no additional work up3New problem (to examiner): additional work up planned4Add up the scores for all problems to obtain a total. Self limited or minor maximum of 2. New problem with no additional work up maximum of 1.
18 Amount and Complexity of Data Reviewed Reviewed DataPointsReview and/or order of clinical lab tests1Review and/or order of radiologyReview and/or order of other medical testsDiscussion of test results with performing physicianDecision to obtain old records or history from someone other than patientReview and summarize old records and/or obtain history from someone else and/or discuss case with another health care provider2Independent review of imaging, tracing, or specimen itselfTotal
19 Risk of Complications, Morbidity/Mortality Minimal—one self-limited or minor problemLow—2 or more self-limited or minor problems; 1 stable chronic illness; 1 acute, uncomplicated illnessModerate—1 or more chronic illness with minor exacerbation; 2 or more stable chronic illnesses; undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; acute complicated injury
20 Risk (continued)High1 or more chronic illnesses with severe exacerbationAcute or chronic illnesses or injuries that may pose a threat to life or bodily functionAn abrupt change in neurologic status
21 Minimal Risk examples Cold, insect bite, tinea corporis Order blood work, chest xray, ECGRecommend rest, gargles, superficial dressing
22 Low Risk Examples 2 or more self limited or minor problems 1 chronic illness that is well controlledAcute illness such as UTI, simple sprain, allergic rhinitisPFT, skin biopsy, non-cardiac imagingOTC meds, physical therapy, minor surgery without risk factors, IV fluid without additives
23 Moderate Risk examples One or more chronic condition, worseningTwo or more stable chronic conditionsAcute illness with systemic symptoms such as pylonephritis, pneumoniaAcute complicated injury such as concussionNew problem needing additional work upStress test, endoscopy, cardiovascular imagingMinor surgery with risk factors, prescription drugs, closed treatment of fracture
24 High Risk examplesOne or more chronic illness with severe exacerbation, abrupt change in neuro statusAcute threatening illnesses such as severe respiratory distress, acute MI, pulmonary embolus, peritonitis, acute renal failureInvasive tests with identified risk factorsElective surgery with risk factorsDrug therapy requiring intensive monitoringDecision not to resuscitate or de-escalate care
25 Summary of Decision Making Summary of Results of Complexity(Level of Medical Decision Making)Straight-forwardLow ComplexModerate ComplexHigh ComplexNumber of diagnoses or treatment options (points)< 1minimal2limited3multiple>4Exten-siveAmount and complexity of data (points)Minimal or low> 4exten-siveHighest RisklowmoderateHighIf all 3 are not at the same level, then level of medical decision making is determined by the second highest indicated.
26 Established Office Visit Level 2 (99212)Level 3 (99213)Level 4 (99214)Level 5 (99215)HistoryProb-focusedExpanded PFDetailedComprehensiveExamMDM(complexity)Straight forwardLowModerateHighApproximate time10 min.15 min.25 min.40 min.Level is determined by at least 2 components in the same level.Level 1 (99211) is a minimal visit that may be done by ancillary staff
27 New Patient/Consultation IIIIIIVVHistoryPFEPFDetailedCompExamMDMSFLowMediumHighNew patient—Has not had any professional face-to-face services from the provider or any provider in the same specialty in the group in previous 3 years.Requires 3 components on the same level.
28 Preventative Services By age, coverage and reimbursement are preset and vary by insuranceMedicare does not cover a routine yearly physicalWelcome physical in first yearOther preventative services and screenings at determined intervalsMust use appropriate codes
29 Counseling/Coordination of Care For an encounter dominated by counseling about a medical condition or coordination of care, time is a determining factor.For outpatient visit, must be face-to-face timeFor inpatient, can be time on unitTime can be estimatedMust document 3 components: total time, at least 50% of the visit was spent counseling, nature of the counseling
30 Incident To Paid at full physician fee schedule amount NPs and other non-physician providers are usually allowed at 85%Usually used for follow up of a physician’s patient following the same plan of care.
31 Incident To Providers Auxiliary personnel: RNs, LPNs, Technicians Non Physician Providers (NPPs): NP, PA, CNS, CNM (can supervise auxiliary personnel for payment, except in hospital outpatient departments)Physical therapists, occupational therapists, clinical social workerOn claim report both name and NPI of initiating physician and supervising physician
32 Requirements Services must be furnished in the office (not hospital) Furnished under direct supervision of a doctorMust have employment relationshipAre integral, although incidental to the doctor’s services.Commonly rendered without a physician charge but incur some expense (for dressing change, drug administration)
33 Direct SupervisionSupervising physician can be any member of the groupMust be present in the office suites and immediately available.Does not need to speak to or lay hands on the patient.
34 Employment Relationship EmployeeLeased employeeIndependent contractor of physician or legal entity that employs or contracts physician
35 Documentation must Identify who rendered the service Indicate supervision requirement is metShow physician’s initiation and continued involvement in treatment planShow that care was reasonable and necessaryShow that care was within the scope of practice of NPP
36 Modifiers25—significant, separate E&M performed by same provider on same day24—unrelated E&M done by provider at post operative visit50—bilateral (pays 150%)51—multiple proceduresDocumentation should show medical necessity and what was done in addition
37 Comprehensive Error Rate Testing CMS program monitors accuracy of claims and paymentsNational error rate is 4.5%Maryland and surrounding states: 4.3%Services associated with errors:Consults 27% Established office visits 21%other outpatient 21%Initial hospital 15% ---Subsequent 13%
38 Billing and Coding TipDocument every visit using a SOAP note with subheads and bulleted points for HPI (OLDCART, PQRST), ROS, related past/family/social history, exam by systems, diagnoses, and treatment plan.You will more easily be able to determine the E&M level, or if you document electronically, a computer program may determine the E&M.
39 Resources Center for Medicare and Medicaid Services www.CMS.hhs.gov (Documentation Guidelines)(1995 Guidelines)(1997 Guidelines)(Claims processing)