Coding, Documentation, and Data Management Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs

Session Objectives zUnderstand basic code systems zUnderstand basic organization and principles of procedure and disease coding zUnderstand basic principles of coding and billing zUnderstand basic principles of documentation

Topics for Discussion zCoding systems zProcedure codes zDisease codes zCoding, billing, and compliance zDocumentation zReferral guidelines and service agreements

How are codes used? zRevenue generation (reimbursement) zDocumentation of services zWorkload and utilization zProductivity zCost analysis zProvider profiles (privileging) zAnalysis, health research, and trending

Coding Systems

Procedure Coding Systems zHealthcare Common Procedure Coding System (HCPCS) zCurrent Procedural Terminology (CPT) zHCPCS Level II (National or HCPCS) zICD-9 PCS  Future: ICD-10-CM and ICD-10 PCS

Disease Coding zInternational Classification of Diseases, Ninth Edition, with Clinical Modifications (ICD-9-CM) zFuture: International Classification of Diseases, Tenth Edition (ICD-10-CM)

Professional & Technical zCodes may not have physician work value zSome codes have technical (TC) and professional (26) components. zProfessional component=physician work (May be billed by audiologists.) zTechnical component=practice expense zMost Audiology codes do not have physician work.

Complexity-based Codes zUnless otherwise specified, procedures are based on complexity  Enter one code per procedure regardless of time spent zMost CPT codes are complexity-based.

Time-based Codes zTime period is specified (e.g. 15 minutes) zEnter one code for each time period zTotal volume=total time  Example: 2 units=30 minutes for a 15- minute procedure zFew Audiology codes are time-based. zTime must be documented.

Audiology Services zCPT codes in the series zTechnical and professional services zDo not require supervision by a physician zPerformed by qualified audiologists zMust be ordered by a physician to be billed.

General Purpose Codes z evaluation of auditory processing and/or aural rehabilitation status z treatment of auditory processing disorder (includes aural rehabilitation) z group treatment zOften used (and abused) for hearing evaluation and treatment, not elsewhere classified

Audiology Treatment Codes zAudiologists cannot be reimbursed for treatment services under Medicare y foreign body removal y cerumen management y vestibular rehabilitation

Implant Services zCochlear implant evaluation: Use audiological assessment codes zPost-op analysis and fitting: y Diagnostic analysis of CI, <7 yoa y Subsequent programming, < 7 yoa y Diagnostic analysis of CI, >7 yoa y Subsequent programming, > 7 yoa zBillable as diagnostic services zCI Rehab (treatment) or 92507?

Vestibular Function Tests zWith electrical recording y spontaneous nystagmus test y positional nystagmus test y caloric vestibular test, each irrigation y optokinetic nystagmus test y oscillating tracking test (pursuit)  sinusoidal vertical axis rotation test

Vestibular Function Tests z use of vertical channel recording zAdd-on code--usually limited to and zNo specific code for saccades (use 92700)

Vestibular Function Tests zObservation without electrical recording zNo reimbursement value y spontaneous nystagmus y positional nystagmus y caloric vestibular test y optokinetic nystagmus

Audiological Assessment Codes z screening test, air only z pure tone audiometry, air only z pure tone audiometry, air/bone z SRT z SRT and speech recognition zNo code for PI/PB (use modifier 22)

Audiological Assessment Codes z comprehensive audiometry zBundled code (includes and 92556) zDo not code separately if all component tests are performed z group audiometric test

Middle-ear Function Tests z acoustic immittance (tympanometry) z acoustic reflexes z acoustic reflex decay

Site of Lesion Tests z filtered speech test z SSW z SSI (ICM or CCM) z tone decay test z SISI z pure tone Stenger test z speech Stenger test z central auditory function test

Less Commonly Used Procedures z Lombard test z SAL z loudness balance test (ABLB) z Bekesy screening test z Bekesy diagnostic test

Electrophysiological Tests z electrocochleography z auditory evoked potentials, screening z auditory evoked potentials (ABR, MLR, late potentials), diagnostic z otoacoustic emissions, screening z otoacoustic emissions, diagnostic z intraoperative monitoring (added on to primary procedure, e.g )

Hearing Aid Services z HAE, monaural z HAE, binaural z hearing aid check, monaural z hearing aid check, binaural zV5014--hearing aid repair z electroacoustic test, monaural z electroacoustic test, binaural

Hearing Aid Services zProgramming--Use or zEar impression--V5275 zReal-ear measurement--V5020 zOtoscopy is part of examination and is not coded separately. Video-otoscopy is diagnostic and is coded as

Hearing Aid Services z97703 (each 15 min)--hearing aid orientation z outcome measures z92507-aural rehabilitation (except implant) zConsidered to be part of fitting*: ydevice ordering/handling (99002) yspecial supplies (99070) ypatient education materials (99071) ygroup patient education (99078) z*not billable by audiologists

Balance Treatment zAudiologists treat vestibular disorders including BPPV. zPeripheral vestibular rehab (canalith repositioning) is within the audiologist’s scope of practice. Code zPT/OT treats global balance problems (sensory integration, proprioception). zDynamic posturography (92548) is within the PM&R scope of practice. zGlobal vestibular rehabilitation (97112).

Audiology: HCPCS Codes zV5008-hearing screening zV5010-V5298--hearing aid services zV5299--miscellaneous hearing service zL8614--cochlear implant device/system zL8619--speech processor replacement zL7510--repair of prosthetic device (not hearing aid)

CPT Modifiers

Why Use Modifiers? zTo indicate that a service was more or less complex than typical zTo indicate that a service was repeated or discontinued zTo add more information regarding the purpose or anatomic site of the procedure zTo help to eliminate the appearance of duplicate billing  To help to eliminate the appearance of unbundling (fragmentation).

CPT Modifiers z22--unusual procedural service z26--professional component (interpretation) z51--multiple procedures during same encounter z52--reduced service. Example: unilateral procedure when bilateral is assumed.

CPT Modifiers z53--discontinued procedure z59--distinct procedural service on same day z76--repeat procedure by same provider z77--repeat procedure by other provider z99--multiple modifiers

Disease Coding

Structure of ICD-9-CM z3-, 4-, and 5-digit codes indicating levels of specificity zUpdated annually by working group zDiseases and injuries ( ) zFactors influencing health status and contact with health services (V-codes) zExternal causes of injury or poisoning (E- codes)

Principles of Disease Coding zGeneral rule: code to the highest degree of medical certainty. zUse the most specific code possible. zAvoid NOS and NEC codes. zNon-physicians may code symptoms. zChoice of disease code has a great affect on reimbursement.

NEC and NOS Codes zNEC--not elsewhere classified (xxx.x8) zNOS--not otherwise specified (xxx.x9) zNEC means that no appropriate code was found in the tabular list based on the information provided. zNOS means that the condition was not adequately described by the provider. zNOS codes are usually not accepted

Outpatient Disease Coding zCondition that is chiefly responsible for the patient’s visit is the primary diagnosis. zPrimary diagnosis may be a disease, condition, problem, symptom, injury, or reason for encounter. zSecondary diagnoses may describe co-existing conditions, symptoms, or reasons zDo not code conditions previously treated and no longer exist. zDo not code “probable”, “suspected”, “questionable”, or “rule out” diagnoses.

Primary and Secondary zPrimary Diagnosis: disease, symptom, condition or reason that is chiefly responsible for the visit. zSecondary Diagnosis: other diagnoses (e.g. relevant chronic conditions), conditions that have impact on care, or other conditions found after study.

Primary and Secondary zFor treatment services: yPrimary Diagnosis: reason that is chiefly responsible for the visit. ySecondary Diagnosis: Condition treated and other diagnoses (e.g. relevant chronic conditions) or other conditions found after study.

Primary and Secondary zFor assessment services: yPrimary Diagnosis: appropriate V-code to indicate the reason for the exam ySecondary Diagnosis: any diagnoses, conditions, or symptoms found after study

V-codes zDo not confuse ICD-9-CM V-codes with HCPCS Level II V-codes. yICD-9-CM codes are diseases, conditions, symptoms, or reasons. yHCPCS Level II codes are procedures.

Audiology: ICD-9-CM V-codes zV19.2 (family history of hearing loss) zV19.3 (family history of ear disorder) zV41.2 (problems with hearing) zV53.2 (fitting/adjustment of hearing aid) zV65.2 (non-organic condition) zV65.43 (counseling for injury prevention) zV71.8 (observation for suspected condition) zV70.5 (exam for military personnel)

Normal Function zThere is no ICD-9-CM code for normal function. Normal function is not coded as a disease. zV65.5 when there are no risk factors. zV71.89 when there is clinical reason to suspect a problem.

Coding and Billing

Caveats zEvery insurance carrier has its own rules. zCoding is not the same as billing. zCoding errors may lead to billing errors zEven accurate coding may lead to errors. zNot all billed codes are reimbursable. zNot all encounter codes are appropriate or billable. zBilling errors, however innocent, may be viewed insurance fraud.

What is Required to Assure Accuracy (compliance)? zBilling codes must match documentation. zDocumentation must support the scope and level of service (complexity or time). zCPT codes must match diagnosis. zServices must be appropriate by provider type. zServices must be ordered by a physician (in writing)

Reasons for Fraudulent Billing zInadequate documentation zImproper coding zServices not provided zFragmentation (unbundling) zLack of medical necessity

Role of the Provider zFully document clinical care zProvider is responsible documentation zUse accurate encounter forms zEncounter form is a tool. Documentation is what is important. zFollow applicable coding and documentation guidelines zAssist in verifying claims

What Can Be Done to Improve Coding? zCoding handbooks and guidelines zStandard encounter forms (super bills) zEducation zGood dialogue with coding and billing officials zElectronic aids (templates, code filters, prompts, taxonomies, e.g. CHCS-2)

Documentation

Principles of Documentation zDocumentation must be: yAccurate--describes the care provided yCodable--supports CPT, ICD, DRG codes yUnderstandable--clear to reader yTimely--written at time patient was seen yError free--stands alone as a legal document

Principles of Documentation zIf ain’t documented, it weren’t done! zAll care must be documented. zAnecdotal or historical events (patient not present) should be documented. zAll documentation must be dated and signed.