1. Coding 2010 ASTHMA Coding 2010 ASTHMA Richard H. Tuck, MD, FAAP

2. Using and Reporting ICD-9-CM Codes Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results, Probable, suspected,questionable, or rule out should not be coded List the ICD-9-CM code that is identified as the main reason for the service first. Next list any current coexisting conditions. Chronic disease treated on an ongoing basis may be coded

3. Asthma ICD Coding Not consistent with current asthma diagnostic criteria in ICD-9 Not consistent with current asthma diagnostic criteria in ICD-9 Will be revised to meet diagnostic criteria in ICD-10 Will be revised to meet diagnostic criteria in ICD-10 Code symptoms until confident of asthma diagnosis Code symptoms until confident of asthma diagnosis

4. Asthma ICD Coding Symptoms 465.9URI 465.9URI 466.0Bronchitis 466.0Bronchitis 466.19Bronchiolitis 466.19Bronchiolitis 486Pneumonia 486Pneumonia 519.11Acute bronchospasm 519.11Acute bronchospasm 786.05Shortness of breath 786.05Shortness of breath 786.06Tachypnea 786.06Tachypnea 786.07Wheezing 786.07Wheezing 786.2Cough 786.2Cough

5. Asthma ICD Coding Asthma Diagnosis Note fifth digit classification Note fifth digit classification –0 unspecified –1with status asthmaticus –2with (acute) exacerbation 493.x Asthma 493.x Asthma

6. Asthma ICD Coding Asthma Diagnosis 493.0Extrinsic asthma 493.0Extrinsic asthma –493.00childhood w/o status –493.01childhood with exacerbation 493.1Intrinsic asthma 493.1Intrinsic asthma 493.2Chronic obstructive asthma 493.2Chronic obstructive asthma 493.81Exercise induced asthma 493.81Exercise induced asthma 493.82Cough variant asthma 493.82Cough variant asthma 493.9Asthma unspecified 493.9Asthma unspecified

7. V - Codes V 65.11 Conference with Parent V 65.11 Conference with Parent V 65.5 Feared Illness / None Found V 65.5 Feared Illness / None Found V 67.9 Follow up Exam V 67.9 Follow up Exam V 67.59 Follow up after Rx V 67.59 Follow up after Rx

8. Time An explicit factor to assist in selecting the most appropriate level of E/M services An explicit factor to assist in selecting the most appropriate level of E/M services When counseling and/or coordination of care are more than 50% of the face to face encounter, then time is the key controlling factor. When counseling and/or coordination of care are more than 50% of the face to face encounter, then time is the key controlling factor. Utilize prolonged services codes (time based) Utilize prolonged services codes (time based) *Documentation in the medical record is a must *Documentation in the medical record is a must

9. Office Visits – New Patient Codes9920199202992039920499205 History Problem Focused Expanded Problem Focused DetailedCompre hensive hensiveCompre Exam Problem Focused Expanded Problem Focused DetailedCompre hensive hensiveCompre Decision Making Straight forward Low complex Moderate complex High complex Time FF 1020304560 Key # 3 of 3 3 of 3 3 of 3

10. Office Visits – Established Patient Codes9921199212992139921499215 History Not Required Problem Focused Expanded Problem Focused Detailed Compre hensive Exam Not Required Problem Focused Expanded Problem Focused Detailed Compre hensive Decision Making Not Required Straight forward Low Complex Mod Complex High Complex Time FF 510152540 Key # 2 of 3

11. Codes9921199212992139921499215 History Not Required Problem Focused Expanded Problem Focused Detailed Compre hensive Required Elements HPI 1-3 ROS N/A PFSH N/A HPI 1-3 ROS 1 PFSH N/A HPI 4+ ROS 2-9 PFSH 1/3 HPI 4+ ROS 10+ PFSH 2/3 Exam Not Required Problem Focused Expanded Problem Focused Detailed Compre hensive Required Elements 1 Area 1 Area 2-4 Areas 5-7 Areas >8 Areas Decision Making Not Required Straight forward Low Complex Mod Complex High Complex Time FF 510152540 Key # 2 of 3

12. Asthma 99213 → 99214 CSHCN CSHCN New Diagnosis New Diagnosis Repeat visit – patient worse Repeat visit – patient worse Comorbidities Comorbidities Lab or Xray ordered Lab or Xray ordered Consultation indicated Consultation indicated Prescription written Prescription written Office procedures required (aerosol, pulse ox) Office procedures required (aerosol, pulse ox) Chronic problem – exacerbation, changes in Rx Chronic problem – exacerbation, changes in Rx Time based problem/ “consultation” Time based problem/ “consultation”

13. Preventive Medicine Services E/M services performed in the absence of a significant problem/abnormality E/M services performed in the absence of a significant problem/abnormality Extent and focus depends on the patient’s age Extent and focus depends on the patient’s age Include counseling/anticipatory guidance/risk factor reduction Include counseling/anticipatory guidance/risk factor reduction Do not include office procedures, ancillary services, and immunizations Do not include office procedures, ancillary services, and immunizations

14. Preventive Medicine Services New Patient Initial E/M of a new patient including an age and gender appropriate history, examination identification of risk factors, ordering of appropriate tests, and counseling RVU/ 2009 Medicare identification of risk factors, ordering of appropriate tests, and counseling RVU/ 2009 Medicare 99381 Age < 1 year 2.51/ $ 90.53 99382 Ages 1 – 4 years2.73/ $ 98.46 99383 Ages 5 – 11 years2.71 /$ 97.74 99384 Ages 12 – 17 years2.95/ $106.40 99385 Ages 18 – 39 years2.95/ $106.40

15. Preventive Medicine Services Established Patient Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk factors, ordering of studies, and counseling RVU/ 2009 Medicare 99391 Age < 1 2.09/ $75.38 99392 Ages 1 – 4 years2.33/ $84.04 99393 Ages 5 – 11 years2.32 /$83.67 99394 Ages 12 – 17 years2.55/ $91.97 99395 Ages 18 – 39 years2.56/ $92.33

16. Preventive Medicine vs E/M Office Visit ? How do you code for asthma management at the time of a preventive medicine visit?

17. 25 Modifier If a significant problem/abnormality is found at a preventive medicine visit: If a significant problem/abnormality is found at a preventive medicine visit: –Code the appropriate E/M visit in addition to 99381 – 99395 99381 – 99395 -Add modifier –25 to the E/M code -If not significant code only 99381 – 99395 - Option: Have patient return for a separate E/M visit for asthma management

18. Office procedures Immunizations Immunizations Minor procedures Minor procedures Lab and x-ray services Lab and x-ray services Medical services Medical services Screening procedures Screening procedures Special services Special services

19. Vaccine Coding Specifics Each vaccine has a specific CPT code Each vaccine has a specific CPT code AMA identifies vaccines pending FDA approval ~ code assigned AMA identifies vaccines pending FDA approval ~ code assigned Each vaccine has an appropriate ICD-9 diagnosis code Each vaccine has an appropriate ICD-9 diagnosis code Each vaccine should be linked to an individual IA (immunization administration) code Each vaccine should be linked to an individual IA (immunization administration) code

20. Immunizations Bill and Document ALL: Bill and Document ALL: –E/M Visit »Office Visit, Preventive Medicine –Immunization Administration »90471 – 90474 »90465 - 90468 (2005 Peds specific) –Vaccine/Toxoid »90476 – 90749 Link to ICD Diagnoses Link to ICD Diagnoses –V20.2 Well Child –Asthma diagnosis –+ Specific Vaccine V Codes

21. H1N1 Influenza Coding CPT CPT –90470 - H1N1 IA, any route, including counseling $24 –90465-90468, 90471-90472 – if directed by plan –G9141- H1N1 IA, any route, including counseling Ohio Medicare $19.95 ICD ICD –90663 – Influenza vaccine, pandemic formulation –G9142 –Influenza A vaccine (H1N1), any route administration –$0 vs. $0.01 charge

22. H1N1 Influenza Testing Coding Rapid Influenza testing Rapid Influenza testing –If testing for two distinct virus strains (A & B) Report test for rapid influenza test twice 87804 87804-59 (distinct procedure modifier)

23. Non Face-To-Face Physician Services Telephone Calls Telephone Calls Reviewing Records/Reports Reviewing Records/Reports Completing Forms Completing Forms Managing, Modifying Care Plans Managing, Modifying Care Plans Case Management Case Management

24. Telephone Services CPT 2008 99441Physician to est patient, parent or guardian 2009 medicare 5 – 10 minutes of medical discussion ($12.62) No related E/M service within previous 7 days No related E/M service in next 24 hours or next available appointment 99441Physician to est patient, parent or guardian 2009 medicare 5 – 10 minutes of medical discussion ($12.62) No related E/M service within previous 7 days No related E/M service in next 24 hours or next available appointment 9944211 – 20 minutes ($24.89) 9944211 – 20 minutes ($24.89) 9944321 – 30 minutes ($38.33) 9944321 – 30 minutes ($38.33)

25. Non Face-to-Face Non-Physician Services CPT 2008 Telephone – by qualified non-physician health care professional No related E/M service previous 7 days No related other service in next 24 hours or next available appointment 2009 medicare Telephone – by qualified non-physician health care professional No related E/M service previous 7 days No related other service in next 24 hours or next available appointment 2009 medicare 989665 – 10 minutes medical discussion ($12.26) 9896711 – 20 minutes ($24.89) 9896821 – 30 minutes ($37.15)

26. Online Medical Evaluation CPT 2008 99444Online E/M service provided by a physician to an est patient, parent, guardian or health care provider Not originating from related E/M service in previous 7 days In response to patient’s online inquiry Using internet or similar communications network Requires “timely response” Permanent storage of encounter ($0.00) 99444Online E/M service provided by a physician to an est patient, parent, guardian or health care provider Not originating from related E/M service in previous 7 days In response to patient’s online inquiry Using internet or similar communications network Requires “timely response” Permanent storage of encounter ($0.00)

27. Non Face-to-Face Non-physician Services CPT 2008 Online Medical Evaluation Online Medical Evaluation 98969Online assessment and management, by non-physician health care professional No related assessment and management service in previous 7 days Using internet or similar electronic communication network In response to patient’s on line inquiry ($0.00) Timely response with permanent storage of encounter 98969Online assessment and management, by non-physician health care professional No related assessment and management service in previous 7 days Using internet or similar electronic communication network In response to patient’s on line inquiry ($0.00) Timely response with permanent storage of encounter

28. CSHCN Children with Special Health Care Needs Case Management Services Process in which a physician is responsible for direct care of a patient, and for coordinating and supervising other health care services required.

29. Case Management Services (new/revised) CPT 2008 Medical team conference (99366 – 99368) added Medical team conference (99366 – 99368) added –99366Direct Contact with Patient and/or Family, 30 minutes or more, non physician participation Physician participation use E/M face to face services –99367W/O Direct Contact (Patient and/or Family not present), 30 minutes or more, physician participation –99368non physician participation 99361 – 99362DELETED 99361 – 99362DELETED

30. Behavior Change Intervention Screening Brief Interventions (SBI) Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow- up Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow- up Examples: Tobacco and Drug/Alcohol SBI Examples: Tobacco and Drug/Alcohol SBI

31. Behavior Change Intervention CPT 2008 99406Smoking and tobacco use cessation counseling visit, 3 – 10 minutes ($12.98) 99406Smoking and tobacco use cessation counseling visit, 3 – 10 minutes ($12.98) 99407> 10 minutes ($24.89) 99407> 10 minutes ($24.89)

32. Behavior Change Intervention CPT 2008 Provided by : Physician or “other qualified health care professional” Provided by : Physician or “other qualified health care professional” E/M Service provided same day must be distinct -25 modifier E/M Service provided same day must be distinct -25 modifier

33. Provide Consultations ! 99241-99245 Payment is 25-42% higher than corresponding new patient office visit codes, and… Payment is 25-42% higher than corresponding new patient office visit codes, and… Documentation requirements for History, Exam, and MDM are the same! Documentation requirements for History, Exam, and MDM are the same! Consult codes are problem-based and can be used for new or established patients Consult codes are problem-based and can be used for new or established patients

34. Consultations – 5 R’s - 2008 REASON: Medically necessary REQUEST : By another physician or other appropriate source RENDER : May initiate diagnostic and/or therapeutic services REPORT : By written report back to the requesting source RETURN : Patient back to requesting physician/source

35. Office Consultation/ New or Est Code9924199242992439924499245 History Problem Focused Expanded Problem Focused Detailed Compre hensive Exam Problem Focused Expanded Problem Focused Detailed Compre hensive Decision Making StraightfdStraightfd Low Complex Mod Complex High Complex Time FF 1530406080 Key # 3 of 3

36. Prolonged Services (99354-99359) Code series defining prolonged services by: Code series defining prolonged services by: –Site of service –Direct or without Direct patient contact –Time Reported in addition to other physician service, including E/M services at any level Reported in addition to other physician service, including E/M services at any level Total time for a given date, even if the time is not continuous Total time for a given date, even if the time is not continuous Time must be of 30 minutes or more Time must be of 30 minutes or more

37. Prolonged Services Direct Patient Care OutpatientInpatient Face to Face 99354 first hour > 30 min > 30 min 99356 first hour > 30 min > 30 min Face to Face 99355 each add 30 min > 75 min > 75 min 99357 each add 30 min > 75 min > 75 min Before or after Face to Face 99358 first hour > 30 min > 30 min 99358 first hour > 30 min > 30 min Before or after Face to Face 99359 each add 30 min > 75 min > 75 min 99359 each add 30 min > 75 min > 75 min

38. CODE FOR ASTHMA PROCEDURES ! CODE FOR ASTHMA PROCEDURES !

39. Use HCPCS Codes for Supplies If not included as standard practice expense for the procedure (Practice expense component of RBRVS) If not included as standard practice expense for the procedure (Practice expense component of RBRVS) CPT 99070 General Nonspecific code for supplies CPT 99070 General Nonspecific code for supplies HCPCS codes are preferable Alphanumeric HCPCS codes are preferable Alphanumeric

40. HCPCS Codes Used to report supplies J1100 - Dexamethasone injection, 1 mg J1100 - Dexamethasone injection, 1 mg J0170 - Epinephrine J0170 - Epinephrine J0696 - Ceftriaxone, per 250 mg J0696 - Ceftriaxone, per 250 mg J7613 - Albuterol for inhalation, 1 unit dose J7613 - Albuterol for inhalation, 1 unit dose

41. Minor Office Procedures CPT RVU/ 2009 Medicare CPT RVU/ 2009 Medicare Aerosol Rx only 94640 0.37/ $13.34 (X-76 for multiple aerosols) Allergy injection (#1)95115 0.29/ $10.46 #2 or more95117 0.35/ $12.62

42. Injection / IV Hydration Codes 2009 90772 →96372 Therapeutic Injection, Sub Q or IM 90772 →96372 Therapeutic Injection, Sub Q or IM 90760→96360 IV Infusion, hydration, initial 31 min to 1 hour 90760→96360 IV Infusion, hydration, initial 31 min to 1 hour 90761→96361 IV Infusion, hydration, each add hour 90761→96361 IV Infusion, hydration, each add hour

43. Special Services and Reports “Modifier-Like” Codes Special Services and Reports “Modifier-Like” Codes 99050 - Services provided in office other than regularly scheduled hours normally closed 99050 - Services provided in office other than regularly scheduled hours normally closed 99051 - Services provided in office during regularly scheduled evening, weekend, holiday hours 99051 - Services provided in office during regularly scheduled evening, weekend, holiday hours 99053 - Services provided 10PM to 8AM at 24 hour facility 99053 - Services provided 10PM to 8AM at 24 hour facility 99058 - Office services on an emergency basis 99058 - Office services on an emergency basis Codes billed in addition to basic service

44. Optimizing Reimbursement Through CPT Coding Utilize Time Time spent in counseling and coordination of care greater than 50% of the visit time Ex: 99213 (15 min) to 99214 (25 min) Asthma requiring extensive counseling Asthma followup visit Document time spent and counseling issues

45. Documentation/ ICD 9 CM ICD coding should support higher levels of coding (medical necessity) ICD coding should support higher levels of coding (medical necessity) 99213 to 99214 99213 to 99214 Code multiple diagnoses Code multiple diagnoses Document chronic condition when an acute problem is presented Document chronic condition when an acute problem is presented –Asthma –Hypoxia

46. Code for extensive medical services Optimize standard office visit services Optimize standard office visit services –Hx, PE, Complexity –Time $ OV < Prev Med < Consultation $ OV < Prev Med < Consultation Utilize prolonged services codes Utilize prolonged services codes –99354-99359 For excess time spent beyond E/M code

47. DOCUMENT ! DOCUMENT ! DOCUMENT !

48. * Turn to AAP for Help – State AAP Pediatric Councils SOAPM aap.org PMO

49. AAP Your CODING CONNECTION Coding & Reimbursement Resources National AAP Coding Hotline: aapcodinghotline@aap.org or 800/433-9016 ext 4022; free service to members and their office staff National AAP Coding Hotline: aapcodinghotline@aap.org or 800/433-9016 ext 4022; free service to members and their office staff aapcodinghotline@aap.org Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner