1. 1 Coding for Local Health Department Clinic & School Sites July 2015 Presented by: Cynthia H. Robinson Internal Policy Analyst III

2. Table of Contents 1. Coding on the PEF 2. Determination of New or Established Patients 3. Coding of Preventive Visits 4. Components for coding “Other than Preventive E/M Visits” – Problem Visits 5. Coding of Problem Visits-New Patients 6. Coding of Problem Visits-Established Patients 7. Multiple Visits for the Same Patient on the Same Day 8. Changes to the PEF 2

3. This presentation was done to aid employees of health department clinics in coding and reporting of services. It could not possibly cover all of the circumstances which occur in these clinics on a day to day basis. This presentation is intended to assist in the training of new employees and to refresh existing employees. 3

4. Guiding Principles 1. Only provide the level of care that is medically necessary per clinical judgment. 2. All RN’s need to provide and document services in accordance with the Core Clinical Service Guidelines (CCSG) and with established best practices. 3. Always code and document exactly what care was provided. 4

5. Coding on the Patient Encounter Form (PEF) 5

6. 6 Coding on the PEF The state-updated CH-45 (PEF) is used in most health department clinics. Some health departments prefer to create and use an abbreviated PEF at off site clinics (e.g. Flu Clinics & School sites). This is entirely permissible. Health Departments using their own forms are responsible for keeping these forms up-to-date, annually.

7. Codes 7 Current Procedural Terminology (CPT) – A set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. CPT codes describe WHAT was done for the patient. International Classification of Disease 9 th Revision 2009 (ICD-9) soon to be ICD-10 – This system is required for reporting diagnoses and diseases to all U.S. Public Health Service and Department of Health and Human Services Programs, such as Medicare and Medicaid. ICD-9 or ICD-10 codes describe WHY it was done.

8. 8 Examples of Codes CLINIC SETTING: 99211– Office or other outpatient visit for the evaluation and management of an established patient that may or may not require the presence of a physician. 99393 – Periodic comprehensive preventive medicine – reevaluation & management of an individual late childhood (age 5 through 11 years) V741 – Special Screening Examination for Pulmonary Tuberculosis / Z11.1-Encounter for screening for respiratory tuberculosis V202 - Routine Infant Or Child Health check/ Z00.129-Encounter for routine child health examination without abnormal findings CPT codes - WHATICD-9/ICD-10 codes - WHY

9. 9 Coding E/M visits in health department clinics consists of: Preventive Visits E/M visits (e.g. well child exam, well woman checks) Evaluation/Management visits, which LHD’s commonly refer to as “problem visits” (e.g. supply visits, STD’s, cancer screenings) Coding E/M visits on the PEF

10. 10 Preventive Visits (e.g. Well Child Exams) Top left corner of PEF Coding on the PEF

11. Other E/M Visits (Problem Visits) Top right corner of PEF 11 Coding on the PEF

12. 12 REMEMBER: 992 codes - for use by physicians and mid level providers only W92 codes - for use by nurses (RN’s) Coding on the PEF – Provider Level

13. 13 Coding on the PEF- CPT codes CPT codes for lab tests, etc. that are done as part of the visit must be.... Checked in the appropriate box on the PEF OR, if the service is not listed on the PEF it should be written in the area provided on the back of the PEF

14. Coding on the PEF - ICD codes ICD codes need to be written on the PEF in the section that corresponds with the service that was provided. ICD codes will reflect why the patient presented. They are assigned based on the presenting problem(s) of the patient. 14

15. Coding on the PEF - ICD codes There is a box for a primary (P) ICD and a secondary (S) if needed. For example...a 4 y/o established patient, receives preventive exam by a nurse (V202-/Z00.129) and also receives vaccines (V069-/Z23). This would be coded on the preventive side of the PEF 15 V069/ Z23 V202/ Z00.129 √

16. 16 ICD Codes In Health Department Sites ICD codes are revised annually and are effective on October 1 of each year. ICD9 is changing to ICD10 effective October 1, 2015. THIS IS IT; It’s really going to happen! Many LHDs create their own listing of most commonly used ICD codes. REMEMBER: These lists must be updated annually. ICD-10 Training on Sept. 3, 2015

17. Determination of New or Established Patients 17

18. 18 New & Established Patients The Patient Encounter Form (PEF or CH-45) distinguishes between New Patients and Established Patients: New Patients visits are coded in the areas highlighted in PINK. Established Patients visits are coded in the areas highlighted in BLUE.

19. New & Established Patients NEW PATIENT - a patient who has not received a professional service (i.e., preventive, problem focused, or procedure) at any health department or satellite clinic in the COUNTY within the past three years. Determination of new or established status is made on a COUNTY basis, not a district basis. 19

20. New & Established Patients The CMS (Clinic Management System) determines whether the patient is new or established at computer registration when the PEF label is created. The computerized registration process is generally not done at the satellite site itself, often making it difficult for the provider to know whether the patient is new or established. 20

21. New & Established Patients If the provider cannot determine whether the patient is new or established by looking at the medical record, the provider should check the appropriate new patient level of visit and the appropriate established patient level of visit on the PEF. (See example on next slide.) This will save time for the provider and for staff doing the data entry. The PEF will not need to be sent back to the provider for determination of level of visit. 21

22. New & Established Patients Clinic Setting: If the system is down or off-site Patient presents to nurse requesting pregnancy test: Staff doing data entry should look at label to determine if it is a new patient or established, then... Enter correct office visit Mark through other visit 22 V7241 √√

23. New & Established Patients Under NO circumstances should staff entering data change the level of visit to accommodate a new or established patient status (unless that level was also marked on the PEF, as discussed in the previous slides). The provider must determine the level of visit. 23

24. Coding of Preventive Visits Preventive visits are reported when the patient receives a full preventive physical exam per the guidelines in the Core Clinical Service Guidelines (CCSG). Coding of these visits require three components: New or established patient status Age of patient Completion of physical exam by protocols which are listed in the CCSG 24

25. Modifier 52 - Preventive Visits: Modifier 52 is not a valid modifier for preventive visits Modifier 52 will no longer be available to add to any Preventive Visit 25

26. Components for coding “Other than Preventive E/M Visits”: 26 Commonly Referred to as “Problem Visits” in Health Department Settings

27. Components of Problem Visits Problem Visits are made up of three components which are directly linked to the coding of these services. 1. History-consists of a combination of three parts: – History of present illness – Review of systems – Past, family and social history 2. Exam 3. Decision making These three components are the driving forces behind the coding of Problem Visits. Understanding these three components is extremely important in accurate coding of problem visits. 27

28. History Subjective – documentation that is reported by the patient. Comparable to the “S” (subjective) portion of the SOAP note Combination of three components – History of present illness – what the patient reports as problems, symptoms, time frames, etc. Review of systems – what body systems are affected by the presenting problems Past, family and social history – what past, familial or social influences there might be on the seriousness and resolution of the problem 28

29. Exam Objective – what the provider notes when assessing the patient The exam is comparable to the “O” (objective) portion of the SOAP note The exam portion will be discussed in detail in the Coding of Problem Visits - New Patients section of this presentation 29

30. Decision Making The decision making component consists of three parts... 1. Presenting problem management options Comparable to the “A” (assessment) portion of a SOAP note. After looking at the patient history and performing exam as needed, the assessment of what the patient’s problem(s) are 30

31. 2. Diagnostic procedures ordered Provider must decide what, if any, diagnostic procedures should be done 3. Management options selected What treatment the patient should receive The last two parts combined are comparable to the “P” (plan) portion of a SOAP note 31 Decision Making

32. Coding of Problem Visits 32 New Patients

33. American Medical Association (AMA) rules require that you have documented some of each of these components for new patients: 1. History 2. Exam 3. Decision making The AMA rules state that you must code Other E/M Office Visits for new patients to the lowest of these three components. By lowest of these three components, they mean the component which has the least impact on the visit. Should you be missing one of the three components on a new patient, an 80000 code will have to be used. This code gives you no reimbursement and no Work Resource Based Relative Values. So the time spent with this patient will be as though it never happened. 33 Coding of Problem Visits – New Patients

34. The exam component will be the lowest of the three components 99% of the time. New patients should be coded by the amount of exam performed (which are commonly referred to as “exam bullets” because this is how they are identified in CPT classification). AMA has determined that all providers have to code to the Lowest component of the visit. 34 Coding of Problem Visits – New Patients

35. 35 Exam – New Patients A complete list of exam bullets can be found in the 1997 Documentation Guidelines for Evaluation & Management Services ( developed jointly by the AMA & HCFA).1997 Documentation Guidelines for Evaluation & Management Services ( developed jointly by the AMA & HCFA)

36. Exam – New Patients – CLINIC The five most common bullets are: General Appearance/Nutritional Status. (Although these appear on two lines of the HP/CH-13 and HP/CH-14 exam forms, they only count as one bullet.) Mood and Affect Orientation Skin (2 bullets possible) Inspection – looking (e.g. pink, tan, intact) Palpation - touching (e.g. warm, dry) Vital signs can be used as an exam bullet also, but three vital signs from the following list MUST be done for it to count as a bullet: Sitting or standing blood pressure Supine blood pressure Height Weight Temperature Pulse Respiration 36

37. Following is a list of the number of exam bullets that corresponds to the level of office visit to code for new patients: 1 to 5 exam bullets = 99201 or W9201 Brief 6 to 11 exam bullets = 99202 or W9202 Expanded 12 to 17 exam bullets = 99203 or W9203 Detailed 18 to 23 exam bullets = 99204 or W9204 Comprehensive A comprehensive office visit has the same requirements as full preventive visit (per the preventive guidelines in the CCSG). If this level of exam is performed, the provider should look at coding a full preventive exam on the patient. 24 or more bullets = 99205 or W9205 Complex Comprehensive and Complex levels of new patient visits should seldom occur in a health department site. These have been addressed here in case of rare emergencies. 37 Coding of Problem Visits – New Patients - CLINIC

38. 38 Coding of Problem Visits – New Patients - CLINIC The AMA expects medical providers to do a more thorough exam, within reason, on a new patient to provide a good base line for future visits (see 907 KAR 3:130).907 KAR 3:130

39. Remember to have some History, some decision making, however the Coding for new patients is directly related to the amount of exam bullets performed, as it’s usually the lowest component in HD. Count the number of exam bullets and code accordingly. 39 Coding of Problem Visits – New Patients - CLINIC

40. Coding of Problem Visits New Patients - SCHOOL According to the Coding Criteria for Coordinated School Health: APRN’s and/or Registered Nurses may code: 99201 &99202, W9201 & W9202 Count the amount of Exam Bullets provided as medically necessary and code one of the two permissible billable codes listed above 40

41. Coding of Problem Visits Established Patients 41

42. To code a Problem Visit for an established patient, the AMA requires that only two of the three components be documented. 1. History 2. Exam 3. Decision making The visit should be coded by the lowest of the two components. 42 Coding of Problem Visits – Established Patients

43. The level of visit chosen for established patients will be driven by the lowest of either the history component or the medical decision making component. Exam performed should be what is required by protocol and medically necessary. 43 Coding of Problem Visits – Established Patients

44. Coding of Problem Visits – Established Patients (Clinic) 99211 and W9211 Brief – No history is taken – Decision making is minimal – No ROS (review of systems) Examples: – Negative TB skin test reading (NEVER write a SOAP note for a negative TB skin test reading. That raises the level of visit and is never medically necessary.) 44

45. Coding of Problem Visits – Established Patients (Clinic) 99212 or W9212 Limited Requires at least 2 of these 3 key components; Problem focused history; Straight forward decision making; Problem focused exam Patients who have one or more self-limited or minor problem(s) Examples Supply Visit (no complaints or problems) STD Visit (no problems or negative results) Head lice (either suspected or found) 45

46. Coding of Problem Visits – Established Patients (Clinic) 99213 or W9213 Expanded Requires at least 2 of these 3 key components; Expanded problem focused history; Expanded problem focused examination; Decision making of low to moderate complexity Examples Pt to receive depo – wt gain 5 lb since last visit, c/o occasional headaches–counseled &depo adm. Positive TB skin test reading Positive STD visit with treatment 46

47. Coding of Problem Visits – Established Patients (Clinic) 99214 or W9214 Detailed Requires at least 2 of these 3 key components; Detailed history; Detailed examination; Decision making of moderate complexity Presenting problems are of moderate to high complexity Examples True contraindication to contraceptive methods OCs - B/P 160/92, c/o severe HA’s daily with visual impairment - no contraceptive given until patient is further evaluated Patients presenting with problems significant enough that more case management is necessary Pt with abnormal breast exam *******Please keep in mind:907 KAR 3:010 Section 4 PHYSICIAN’S MEDICAID only pays Doctors for TWO 99214 visits every 12 months 47

48. Coding of Problem Visits – Established Patients (Clinic) 99214 or W9214 Detailed Requires at least 2 of these 3 key components; Detailed history; Detailed examination; Decision making of moderate complexity Presenting problems are of moderate to high complexity Example: Positive Preg test – initial PN Visit - HIGH RISK PREGNANCY - includes 2 or More RISK Factors See below for RISK Factor examples: - History of Miscarriage/High Blood Pressure/Early labor - Preeclampsia - STI with pregnancy - Smoker - Obesity - Age (under or over) 48

49. Coding of Problem Visits – Established Patients (Clinic) 99215 or W9215 Comprehensive Requires at least 2 of these 3 key components: Comprehensive history; Comprehensive examination; Decision making of high complexity Presenting problems are of moderate to high complexity Significant risk to the life of the patient Examples HIV Rape Abrupt neurological changes Anaphylactic reaction to vaccine Emergency treatment necessary via EMS *******Please keep in mind:907 KAR 3:010 Section 4 PHYSICIAN’S MEDICAID only pays Doctors for TWO 99215 visits every12 months 49

50. Coding of Problem Visits – Established Patients (School) 99211 and W9211 Brief – No history is taken – Decision making is minimal/ low severity/acuity – No ROS (review of systems) Patients who have simple self-limited or minor problem(s) according to Coding Criteria for Coordinated School Health Examples: Vomiting/diarrhea / Upper respiratory symptoms / Headache / Sprain / Strain / Bites / Blood Glucose with carb counting / Seizure disorder / Asthma / Allergies / Sterile dressing and soaks / Collecting and/or performance of tests – blood glucose, urine glucose, pregnancy testing / 50

51. Coding of Problem Visits – Established Patients (School) 99212 or W9212 Limited Requires at least 2 of these 3 key components; Problem focused history; Straight forward decision making; complex severity/acuity Problem focused exam; Patients who have more complex self-limited or minor problem(s) according to Coding Criteria for Coordinated School Health Examples: Vomiting/diarrhea / Upper respiratory symptoms / Headache / Sprain / Strain / Bites / Diabetes / Seizure disorder / Asthma / Allergies / Sterile dressing and soaks / Follow-up for acute illnesses and injuries 51

52. Multiple Visits for the Same Patient on the Same Day 52

53. A 25 modifier may be reported with a Preventive visit, if there is a significant enough and separately identifiable problem. The 25 modifier would be listed with problem-focused E/M visit. When immunizations are given, problem-focused E/M with a 25 modifier may be reported if there is a distinct and separately, identifiable reason for the E/M visit (i.e., a different diagnosis code). When an E/M is reported on the same day as another procedure, such as a MNT; the E/M will require a 25 modifier and the diagnosis code for the E/M needs to different from the diagnosis code for the MNT. 53 The 25 modifier is located beneath the Other Than Preventive codes section. You may either check or circle the 25. Multiple Visits for the Same Patient on the Same Day with Different Problem (Clinic) OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL  CPT NEW Visit Type  CPT EST. Visit TypePROVIDER 99201 Brief99211 Brief 99202 Expanded99212 Limited 99203 Detailed99213 Expanded 99204 Comprehensive99214 DetailedICD (P) 99205 Complex99215 Comprehensive 25 MODIFIER Separate E/M by same provider/same day  NURSE ICD (S) W9201 BriefW9211 Brief W9202 ExpandedW9212 Limited W9203 DetailedW9213 Expanded REF/DISP W9204 ComprehensiveW9214 Detailed W9205 ComplexW9215 Comprehensive

54. Example of when to use the 25 Modifier: (Clinic) 39 year old established pt comes in for Family Planning preventive visit, while doing this pt’s family planning preventive visit, the APRN finds vaginal warts, and with the permission of the pt, treats. Coding would consist of: 99395 9921325 54

55. Another Example of when to use the 25 Modifier: (Clinic) 17 year old established pt comes in for family planning supplies and RN finds out she has not received the Gardasil vaccine. Pt wants to receive this vaccine and is counseled per component. Coding would consist of: W921225 90460 90649 55

56. Guiding Principles 1. Only provide the level of care that is medically necessary. 2. All RN’s need to provide and document services in accordance with the Core Clinical Service Guidelines (CCSG) and with established best practices. 3. Always code and document exactly what care was provided. 56

57. PEF CHANGES : NDC Number for Injectable Drugs and IUD’s Vaccines Codes: Addition of three new CPT Codes for new vaccines 90651 - HPV9 90620 – MENB – Bexsero 90621 – MENB – Trumenba 57

58. References: 1) Current Procedural Terminology 2015 2) International Classification of Disease 9 th Revision 2013 3) International Classification of Diseases 10 th Revison 2014 4) 1995 CMS document: Documentation Guidelines to Evaluation & Management Services 5) 1997 CMS document: Documentation Guidelines to Evaluation & Management Services 6) CMS Evaluation & Management Service Guide 7) DPH Policy: Coding Criteria for Coordinated School Health 58

59. Questions: Email: Localhealth.helpdesk@ky.govLocalhealth.helpdesk@ky.gov Phone: 502-564-6663 Option 1 59