Coding and Billing in the ICD-10 Era Daniel A. Ostrovsky, MD FAAP FACP Chief Coding Consultant Duke Pediatrics Assistant Professor, Internal Medicine Pediatrics Duke University Medical Center

Objectives Understand what an ICD-10 Code and CPT code are. Understand what an ICD-10 Code and CPT code are. Understand how to appropriately choose Evaluation and Management codes Understand how to appropriately choose Evaluation and Management codes Understand how to appropriately document for chosen E&M codes Understand how to appropriately document for chosen E&M codes

What We Know Providers tend to underestimate the services they provide. Providers tend to underestimate the services they provide. Provider education on the “Business” of medicine is poor. Provider education on the “Business” of medicine is poor. Fear of auditing leads to under coding. Fear of auditing leads to under coding. Ambiguous guidelines lead to significant variance in how providers code for services. Ambiguous guidelines lead to significant variance in how providers code for services.

ICD-10 Designed to increase specificity of disease characterization and better characterize illness severity Designed to increase specificity of disease characterization and better characterize illness severity Better codified data means Better codified data means –More accurate identification of patients for research –More accurate characterization of provider case mix index –More accurate characterization of patient severity of illness –Better reimbursement and fewer claims denials

ICD-9 vs. ICD-10

Anatomy of an ICD-10 Code

What does this mean for you? Most providers currently use a relatively small code set of diagnoses regularly (approximately 20-50) Most providers currently use a relatively small code set of diagnoses regularly (approximately 20-50) For many codes in ICD-9 there is a single matching code in ICD-10. For many codes in ICD-9 there is a single matching code in ICD-10. The biggest expansion of codes are in surgical or procedural specialties where site, location, laterality, and phase of care lead to lots of possible combinations. The biggest expansion of codes are in surgical or procedural specialties where site, location, laterality, and phase of care lead to lots of possible combinations. For most, selecting appropriate codes won’t seem very different!

Reminders for Documentation ICD-10 specificity requires documentation of the following whenever possible/relevant ICD-10 specificity requires documentation of the following whenever possible/relevant –Acuity (acute or chronic) –Site Specificity (anatomic location) –Laterality (right, left, bilateral) –Timing of Care (initial, subsequent, sequela) –Manifestations ( “due to”- secondary manifestations of or external cause of a primary disease or injury) –Staging (eg. CKD stage II) –Status (History/Resolved/Remission) –Type (eg. DM II, bacterial/viral, simple/complex)

ICD-10 “Extras” “Additional” Codes “Additional” Codes –Coding for tobacco exposure in most chronic respiratory conditions. –Coding for insulin usage in Type II DM –Coding external causes of injury “Combination” Codes “Combination” Codes –Eg. Mild intermittent asthma with exacerbation as opposed to mild intermittent asthma + wheezing –Type II DM with diabetic nephropathy, etc.. –Allergic rhinitis due to pollen

Guidance for Code Selection In many cases, your documentation may be more specific than an available ICD-10 code. Choose the most specific! In many cases, your documentation may be more specific than an available ICD-10 code. Choose the most specific! Don’t select “unspecified” options unless they are truly clinically unknown Don’t select “unspecified” options unless they are truly clinically unknown Pick age and sex appropriate codes Pick age and sex appropriate codes Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Make sure those specific codes appear in your documentation Make sure those specific codes appear in your documentation

Coding Uncertain Diagnoses

Professional Coding Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Hospital Coding If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established. If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established. Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. Make sure these are part of your clinical documentation!

Just like before… You should be DOCUMENTING as specifically as possible including relevant clinical detail You should be DOCUMENTING as specifically as possible including relevant clinical detail Code the diagnoses you are managing and change/modify them as appropriate Code the diagnoses you are managing and change/modify them as appropriate Keep problem lists updated Keep problem lists updated Use appropriate codes that are age and sex appropriate Use appropriate codes that are age and sex appropriate Have documentation that supports the selected codes Have documentation that supports the selected codes

So what’s changed??? Now insurance companies have more specific diagnoses to decide whether to pay or deny your claim! Now insurance companies have more specific diagnoses to decide whether to pay or deny your claim! Value Based Care is knocking at the door and failure to document and code thoroughly and specifically will have multiple downstream ramifications Value Based Care is knocking at the door and failure to document and code thoroughly and specifically will have multiple downstream ramifications EMR’s have been a double-edged sword EMR’s have been a double-edged sword –Pulls data quickly together but is the data accurate? –Allows efficiency shortcuts but are they accurate?

We all have to do our part!

Excellent FREE Resources ICD-10 lookup by code or text word ICD-10 lookup by code or text word – CMS ICD-10 Pediatrics Resource Page CMS ICD-10 Pediatrics Resource Page – ICD 10 Consult 2016 Free (Free App for mobile devices by Evan Schoenberg) ICD 10 Consult 2016 Free (Free App for mobile devices by Evan Schoenberg)

Level of Service Coding/Billing

Advanced Practice Providers –When Billing for Services Bill independently Bill independently –The Supervising MD does not need to be in the office suite Bill in the supervising providers number when “sharing” the visit with the provider Bill in the supervising providers number when “sharing” the visit with the provider –only allowed for inpatient, hospital based clinic, or ED settings Very Important – Procedures, Critical Care, Consultations cannot be billed as shared. The APP must bill in his/her name if s/he is performing the procedure.

Shared Visit When an APP and their supervising physician share a visit together, the service can be billed in either the APP’s number or the supervising physician’s number. The following are the guidelines to follow when billing a shared visit: When an APP and their supervising physician share a visit together, the service can be billed in either the APP’s number or the supervising physician’s number. The following are the guidelines to follow when billing a shared visit: A shared visit is a medically-necessary encounter with a patient where a physician and a qualified APP each perform and document a substantive portion of the evaluation and management visit, face-to-face with the same patient on the same date of service. A shared visit is a medically-necessary encounter with a patient where a physician and a qualified APP each perform and document a substantive portion of the evaluation and management visit, face-to-face with the same patient on the same date of service. Each provider, the MD/DO and APP, would perform parts of the service and personally document their parts. Each provider, the MD/DO and APP, would perform parts of the service and personally document their parts. –One cannot document for the other. –Each provider’s documentation should be separate and patient specific. Resident/Fellows cannot share visits with APP’s Resident/Fellows cannot share visits with APP’s Applies only to Inpatient, hospital based clinic, or ED

CPT Current Procedural Terminology Current Procedural Terminology Standardized codes used for billing Standardized codes used for billing Codes available for every type of service provided Codes available for every type of service provided Linked to ICD codes to justify services provided. Linked to ICD codes to justify services provided.

Evaluation and Management Coding Elements History History Physical Exam Physical Exam Medical Decision Making Medical Decision Making Face to Face Time Face to Face Time Guidelines developed by CMS (Centers for Medicare and Medicaid Services)

Medical Decision Making Presenting problems Presenting problems Number and complexity Number and complexity Data Data Type of tests Type of tests How they are reviewed How they are reviewed Risk Risk Multidimensional assessment Multidimensional assessment

Problem Points Eg. Bug bite, simple strain/sprain Eg. Asthma, Eczema Eg. Asthma, ADHD, Eczema Eg. AOM, SOB, Dizziness Eg. Headache, abdominal pain Add up the points to get a total. For example, a child being seen for an exacerbation of their asthma who also has allergic rhinitis which is well controlled on current therapy would garner 2 points for the asthma with exacerbation and 1 point for the allergic rhinitis giving a problem point total of 3.

Data Points You only get 1 point for ordering/reviewing multiple lab tests You must document your personal read of an image, tracing, or specimen to get the points for an independent review

Risk Four levels Four levels –Minimal –Low –Moderate –High Three Dimensions Three Dimensions –Presenting Problems –Management Options –Diagnostic Procedures

Choose the highest level of risk!!!

Medical Decision Making Putting it All Together Two out of three factors must meet or exceed the requirements for any given level of medical decision making.

“The Table” HistoryExamMDMFace-to-face$$ 99211Supervision Only Straightforward5 minutes$ HPI: 1-3 elements “Problem Focused” 1 system “Problem Focused” Straightforward10 minutes$ HPI:1-3 elements ROS: 1system “Expanded” 2-7 systems One element per system “Expanded” Low15 minutes$ HPI: 4+ elements ROS: 2-9 System 1/3 P/F/SHx “Detailed” 2-7 systems At least one of the systems having at least 2 elements noted “Detailed” Moderate25 minutes$ HPI : 4+ elements Or Status of 3 active or inactive problems ROS:10+ system 2/3 P/F/SHx “Comprehensive” 8+ systems Single element from each acceptable “Comprehensive” High40 minutes$114.00

Billing for Time Counseling To be used when >50% of the visit is spent in teaching/counseling the patient in regard to the presenting issue. To be used when >50% of the visit is spent in teaching/counseling the patient in regard to the presenting issue. This is different then extended face to face time. This is different then extended face to face time. Documentation Statement Documentation Statement – eg. For “I spent 15 minutes face to face with the patient and family in which 10 minutes were spent counseling the parents in supportive care for URI and proper sleeping position.” “I spent 15 minutes face to face with the patient and family in which 10 minutes were spent counseling the parents in supportive care for URI and proper sleeping position.”

Inpatient Time Based Billing Time spent must be ON THE PATIENT WARD Time spent must be ON THE PATIENT WARD Time includes only the EXCLUSIVE time spent in the management and care of the specific patient Time includes only the EXCLUSIVE time spent in the management and care of the specific patient New Established

Modifier 25 Used when a separate and identifiable procedure is performed. Used when a separate and identifiable procedure is performed. –Ex: Incision and Drainage of an abscess –Administration of vaccines in a non-hospital based clinic Used for a “Split visit” Used for a “Split visit” –Patient presents for a preventative visit but also has an acute issue which you manage and clearly document the separate issue. Need to be linked to an appropriate ICD code. Need to be linked to an appropriate ICD code.

Modifier 25 Examples I&D of Abscess $88 I&D of Abscess $88 Joint Injection/aspiration $45 Joint Injection/aspiration $45 Wart Destruction $86 Wart Destruction $86 Removal of Cerumen impaction $40 Removal of Cerumen impaction $40 Reduction Nursemaid’s elbow 24640$93 Reduction Nursemaid’s elbow 24640$93 Ganglion Cyst aspiration 20612$48 Ganglion Cyst aspiration 20612$48 Prolonged Services Prolonged Services –1 st hour 99354$85 –Each additional 30 minutes 99355$84

Preventive Service Visits Well Child Checks have CPT codes based on the age of the patient Well Child Checks have CPT codes based on the age of the patient –<1y –1-4 y –5-11y –12-17y –18-39y Need to be linked to an appropriate ICD-10 code. Need to be linked to an appropriate ICD-10 code. Z (Routine WCC without abnormal findings) Z (Routine WCC without abnormal findings)

You Code It!!! (Time Permitting)

    Hx: 5 elements ROS: At least 2 (GI, GU) P/F/SHx: 3/3 Hx: 5 elements ROS: At least 2 (GI, GU) P/F/SHx: 3/3 Detailed problem focused (99214) Detailed problem focused (99214) PE: 5 Systems with at least 2 elements per system PE: 5 Systems with at least 2 elements per system Detailed problem focused (99214) Detailed problem focused (99214) MDM: Problems: New problem with no additional w/u (3 points)=Moderate Data Points: 0 Risk: Moderate- prescription drug management 2/3 moderate or higher so moderate MDM (99214) MDM: Problems: New problem with no additional w/u (3 points)=Moderate Data Points: 0 Risk: Moderate- prescription drug management 2/3 moderate or higher so moderate MDM (99214) Code: Could be based on just H&P but MDM supports as well. Code: Could be based on just H&P but MDM supports as well.

Split Visit URI documentation yields linked to acute upper respiratory infection, unspecified site J06.9 Modifier 25 4 yo WCC CPT linked to WCC Procedures Vision Hearing Developmental Screen 96110

Hx : 2 elements, ROS 2 systems Hx : 2 elements, ROS 2 systems Expanded Problem Focused (99213) Expanded Problem Focused (99213) PE: 2 systems PE: 2 systems Detailed Problem Focused (99214) Detailed Problem Focused (99214) MDM: MDM: Problems: Established problem stable or improving (1 point) Data: Reviewed Throat Cx (1 point) Risk: One self-limited problem Overall MDM minimal (99212) Code: /3 meet requirements.

Hx: 4 elements, PMHx,1 ROS Hx: 4 elements, PMHx,1 ROS Expanded (99213) Expanded (99213) PE: 2 organ systems with single element in each PE: 2 organ systems with single element in each Expanded (99213) Expanded (99213) MDM: MDM: –Problem: 1 minor, self- limited problem (1 point) –Data: 0 –Risk: Low (OTC med) Overall MDM is straightforward (99212) Overall MDM is straightforward (99212) Code: Code: /3 support the dx code chosen.

Hx:4+Elements, ROS 2+, PMHx, FHx Hx:4+Elements, ROS 2+, PMHx, FHx Detailed (99214) Detailed (99214) PE: 5 systems PE: 5 systems Detailed (99214) Detailed (99214) MDM MDM –Problem: New problem with planned further workup (4 points) –Data Points: culture sent (1 Point) –Risk: Prescription drug management (moderate) Overall MDM: Moderate (99214) Overall MDM: Moderate (99214) Procedure: I&D Procedure: I&D Code: Code: Modifier 25 with procedure linked to cutaneous abscess of buttock L02.31 Modifier 25 with procedure linked to cutaneous abscess of buttock L02.31

Hx: 4+Elements, ROS >10 PFSHx Hx: 4+Elements, ROS >10 PFSHx Comprehensive (99215) Comprehensive (99215) PE 8+ organ systems PE 8+ organ systems Comprehensive (99215) Comprehensive (99215) MDM MDM –Problem: Established problem worsening (2 points) Low –Data: Order CXR 1 point, personal review 2 points. 1 point for Pulse ox Total=4 points High –Risk: High Overall MDM=High (99215) Overall MDM=High (99215) Procedure: nebs Procedure: nebs Code: modifier 25 procedure linked to Moderate persistent asthma with exacerbation J45.41 Code: modifier 25 procedure linked to Moderate persistent asthma with exacerbation J45.41 Moderate Persistent asthma Moderate Persistent asthma with acute exacerbation- No clear source for exacerbation. Not responding adequately to nebs here. Will require further management in ER for his severe sx.

Hx: 4+ elements, 2+ ROS 2+, 2/3 PFSHx Hx: 4+ elements, 2+ ROS 2+, 2/3 PFSHx Detailed (99214) Detailed (99214) PE: 8+ systems PE: 8+ systems Comprehensive (99215) Comprehensive (99215) MDM: MDM: –Problem: New problem without additional workup planned (3 points) –Data: UA/Ucx (1 point) –Risk: Acute illness with systemic sx. (moderate) Overall MDM: Moderate (99214) Overall MDM: Moderate (99214) Code: linked to Fever, unspecified R50.9 Code: linked to Fever, unspecified R50.9

Hx: 4+ elements, ROS 3 systems, PM/SHx Hx: 4+ elements, ROS 3 systems, PM/SHx Detailed (99214) Detailed (99214) PE: 7 systems PE: 7 systems Detailed (99214) Detailed (99214) MDM: MDM: –Problem severity: New Problem, further workup planned. 4points –Data: UA/Ucx,1 point= minimal –Risk: Rx management=moderate Overall MDM=moderate (99214) Overall MDM=moderate (99214) Code: Code: Hx and PE not suggestive of vaginitis or STD or other abdominal process.

Hx: 4 elements, 1 ROS, PMHx Hx: 4 elements, 1 ROS, PMHx Expanded (99213) Expanded (99213) PE: 2 Systems one with 2+ elements PE: 2 Systems one with 2+ elements Detailed (99214) Detailed (99214) MDM: MDM: –Problem: Established Problem, worsening (2 points) (Low) –Data:0 –Risk: Prescription Drug Management=Moderate Overall MDM=Low (99213) Overall MDM=Low (99213) Code: linked to allergic eczema L20.84 Code: linked to allergic eczema L20.84 Allergic

Hx: 4+ elements, 2+ ROS, P/SHx Hx: 4+ elements, 2+ ROS, P/SHx Detailed (99214) Detailed (99214) PE:8+systems PE:8+systems Comprehensive (99215) Comprehensive (99215) MDM MDM –Problem: New problem with further workup (4 points) (High) –Data: Flu PCR, 1 point –Risk: Prescription drug management (Moderate) Overall MDM: Moderate (99214) Overall MDM: Moderate (99214) Code: linked to cough R05 Code: linked to cough R05

Hx: 4+ elements, 2+ ROS, P/SHx Hx: 4+ elements, 2+ ROS, P/SHx Detailed (99214) Detailed (99214) PE: 7 systems PE: 7 systems Detailed (99214) Detailed (99214) MDM: MDM: –Problem: New problem no further workup (3 points) –Data:0 –Risk: acute self-limited problem=Low –Overall MDM: Low (99213) Code: linked to J06.9 Acute URI of unspecified site Code: linked to J06.9 Acute URI of unspecified site 2/3 support this code and the nature of the problem supports the extent of history and PE. 2/3 support this code and the nature of the problem supports the extent of history and PE.

Time Based Coding Time Based Coding 30 min 30 min Code: linked to encounter for pregnancy test, result positive Z32.01 Code: linked to encounter for pregnancy test, result positive Z32.01

Link to Dan’s Medical Decision Making Calculator (Proprietary for your personal use only) Dan Ostrovsky’s Medical Decision Making Calculator (Excel) calculator%20final.xlsx?dl=0

SPECIAL THANKS Tammy Clay, PDC Chief Compliance Officer Jessica Ferrari, Pediatrics Revenue Manager Danielle Graf, Pediatrics Revenue Manager Melissa Sangster PDC Revenue Manager

References aappediatric coding newsletter. The AAP peer-reviewed coding and Nomenclature Newsletter Vol.4, Number aappediatric coding newsletter. The AAP peer-reviewed coding and Nomenclature Newsletter Vol.4, Number AAP Coding Calculator *subscription to coding newsletter required AAP Coding Calculator *subscription to coding newsletter required AAP Coding Calculator AAP Coding Calculator AAP NC 2007/8 Medicaid Reimbursement Survey AAP NC 2007/8 Medicaid Reimbursement Survey AAP NC 2007/8 Medicaid Reimbursement Survey AAP NC 2007/8 Medicaid Reimbursement Survey Hearing Screening Coding Fact Sheet for Primary Care Pediatricians Hearing Screening Coding Fact Sheet for Primary Care Pediatricians Hearing Screening Coding Fact Sheet for Primary Care Pediatricians Hearing Screening Coding Fact Sheet for Primary Care Pediatricians Jensen PR. Coding Routine Office Visits:99213 or Family Practice Management September Jensen PR. Coding Routine Office Visits:99213 or Family Practice Management September Physicians Computer Company Physicians Computer Company Physicians Computer Company Physicians Computer Company ICD-10-CM The Complete Official Draft Code Set ICD-10-CM The Complete Official Draft Code Set