1. Coding and Billing Basics For the Pediatric Nurse Practitioner September 2017
Daniel Ostrovsky, MD, FAAP, FACP
Assistant Professor of Pediatrics and Internal Medicine
Lead Physician Coding Liaison Department of Pediatrics
Duke University

2. Objectives Understand CPT and ICD terminology
Review key documentation elements to support LOS billing
Review how to correctly select the level of service (LOS)
Review Time based billing

3. CPT Current Procedural Terminology Standardized codes used for billing
Codes available for every type of service provided
Example: established outpatient office visit level 4 = 99214
CPT code

4. ICD-10 International Classification of Diseases 10th edition
A database of codes for all potential diagnoses
Eg. Right acute suppurative otitis media without perforation, non-recurrent H66.001
Needs to be paired with an appropriate CPT code when used for billing purposes
ICD-10 code
Current edition utilized in US which went into effect 10/1/2015

5. ICD-10 Specificity
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)
Acuity- acute sinusitis, other vs. chronic sinusitis, other
Site- acute maxillary sinusitis vs. chronic maxillary sinusitis
Laterality Right acute suppurative otitis media without rupture of the tympanic membrane
Manifestation DM with CKD- You code the diabetes with CKD and then code the CKD stage (which is a manifestation of the DM)
Staging- CKD further specified by stage 1-5
Status- AML in remission, not having achieved remission, in relapse
Type- Complex or simple febrile convulsions

6. Guidance for Code Selection
Don’t select “unspecified” options unless they are truly clinically unknown
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.
Make sure those specific codes appear in your documentation
Always document the important clinical features as ICD-10 is not perfect and in some cases already outdated in the way it classifies diseases
Eg. CKD most current uses both GFR and Albumin categories but ICD-10 only has GFR

7. Evaluation and Management Coding Elements
History
Physical Exam
Medical Decision Making
Face to Face Time
Medical Decision Making should be the most important of the elements in selecting a LOS

8. Documentation

9. Documentation Fails

10. Professionalism Incomplete or incorrect documentation
Puts patients at risk for medical errors
Can delay care delivery
Decreases efficiency for colleagues and consultants who share in the care of your patients
Can cause patient dissatisfaction or grievances as now they have easy access to provider direct documentation through EMR’s

11. 4+ TO SUPPORT Highest Level Billing
History Elements
Location
Duration
Timing
Quality
Severity
Modifying Factors
Context
Associated Symptoms
4+ TO SUPPORT Highest Level Billing

12. Physical Exam Systems
Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
System elements usually include inspection, palpation, and auscultation, as appropriate

13. Review of Systems Constitutional Eyes ENT CV Respiratory GI GU MSK
Integumentary/Skin
Neuro
Psych
Endocrine
Heme/Lymph
Allergic/Immune
10+ TO SUPPORT LEVEL 4 & 5 CONSULT
“A 10+ ROS WAS NEGATIVE EXCEPT AS NOTED IN THE HPI OR BELOW”
(Complete ROS)
“A ROS WAS NEGATIVE EXCEPT AS NOTED IN THE HPI OR BELOW”
At least 2 systems must be specifically documented
(Extended)

14. Elements of the History, Physical, and Review of Systems

15. Medical Decision Making

16. Problem Points
A New problem is only new on the first date you evaluate it. On subsequent visits it is an established problem.
TIP: A single Dx may have many problems which you are evaluating. If you document the evaluation and management of these problems they COUNT towards your total.
TIP: Documentation of the status of 3 problems counts as highest level of service documentation for the HPI portion of the history
Take point total and add 1 to get LOS for outpatient and consult LOS (or any where there are 5 levels) Subtract 1 from total to get LOS for those with 3 LOS CF
Pneumonia
Malabsorption
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.

17. Data Points 1 2 Order Labs or review Labs
Order Radiology or review Radiology
Order Non-invasive or review Non-invasive medicine test
Discuss test with Interpreting (Billing) MD 2
Direct visualization and independent interpretation of a study that was previously interpreted by another provider
Decide to review old records or obtain history from another party
Review and summarize old/other records or information from another party
TIP: A Pulse Ox is a medicine test
If taking info from a third party you get the 2 points but not the 1 for deciding to get it (per Duke Compliance)
You only get 1 point for ordering/reviewing multiple lab tests
You must document your personal read of an ECG or XR to get the points for an independent review

18. Data Documentation Document your chart review and sources of history
“ The HPI represents the integration of chart review and history obtained from xxx”
Document your review of lab, radiology, or medicine test reports
Document your personal interpretation of an image or tracing in addition to reviewing the report

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

20. Risk High Risk (Level 5 Outpatient/Consult/ER /Level 3 Inpatient)
Chronic illness with severe exacerbation, progression, or side effects from treatment
Any illness which poses a threat to life or bodily function
Parenteral controlled substances
Drug therapy requiring monitoring for toxicity
Administration of cytotoxic chemotherapy is always considered high risk under management options when monitoring of blood cell counts is used as a surrogate for toxicity.
Drugs that have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at concentrations close to the upper limit of the therapeutic range and may require intensive clinical monitoring. Need to provide documentation in the medical record of drug levels obtained at appropriate intervals.

21. Risk
Moderate Risk (Level 4 Outpatient/Consult/Level 2 Inpatient; Level 3/4 ER)
Prescription Drug Management
1 Chronic illness with mild exacerbation, progression or side effects of treatment
2 or More chronic illnesses managed
Acute complicated illness or injury
Systemic involvement (eg. Fever, rash, multiple organs)
Undiagnosed new problem with uncertain prognosis

22. Risk Low Risk (Level 3 Outpatient/Consult/ER /Level 1 Inpatient)
Acute uncomplicated illness
One stable chronic illness
Over the counter medications

23. Choose the highest level of risk!!!
99212
99213
Choose the highest level of risk!!!
99214
99215

24. Medical Decision Making Putting it All Together1 2 3 2 3 4 5
Outpatient/Consult
Inpatient level
Eg. Low complexity problem + minimal complexity Data + Moderate complexity Risk= Low Complexity MDM 99213
Ie. 2 out of 3 must be equal to or greater then the selected LOS
Explain why no level 1 listed
Two out of three factors must meet or exceed the requirements for any given level of medical decision making.

25. Medical Decision Making

26. Time Based Billing

27. Time Based Billing for Counseling and Coordination of Care

28. To be used when >50% of the total time is spent in teaching/counseling/coordinating care of the patient.
This is different from extended face to face time. (Prolonged Services)
If time is DOCUMENTED then it will be used as the key controlling factor in the selection of the EM code.

29. Outpatient Time Based Billing
Only the time spent face to face counts
Documentation Statement
eg. For 99213
“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.”
EST PAT
Face-to-face
99211
5 minutes
99212
10 minutes
99213
15 minutes
99214
25 minutes
99215
40 minutes
New Patient

30. Inpatient Time Based Billing
Time spent must be face to face or ON THE PATIENT WARD/MEDICAL UNIT
Time includes only the EXCLUSIVE time spent in the management and care of the specific patient
Documentation
Eg For “I spent 35 minutes face to face or on the medical unit with the patient and family in which > 50% were spent in counseling and coordination of the asthma management of the patient”

31. If a time based statement is used, it will determine the level of service instead of medical decision making

32. Billing for multiple services

33. Modifier 25
Used when you provide an evaluation and management service (such as an urgent visit) and a separately identifiable procedure on the same day
Procedures are the most common example
The modifier is associated with the evaluation and management code
(eg. The established outpatient visit code)
Services that have a PROFESSIONAL component to them. Not labs or nursing services for eg.

34. Modifier 25 Examples I&D of Abscess 10060 $88
Joint Injection/aspiration $45
Wart Destruction $86
Removal of Cerumen impaction $40
Reduction Nursemaid’s elbow $93
Ganglion Cyst aspiration $48
Prolonged Services:
If this is spent counseling then you need to first get to time threshold for a (40 minutes) Then you need an additional 30 minutes to be able to bill (70 minutes).
If problem based billing (not counseling), you need 30 minutes beyond the time threshold for that level of visit.
Eg (25 minutes) you need to spend 55 minutes face-to-face to bill for prolonged services 99354(1st hour). To bill (add’l 30 min) you would need to spend 100 minutes face-to face with the patient.
Note: Face-to-face means physically in the room with the patient. Not just that the patient is in the office getting therapy.

35. Advanced Practice Providers
When Billing for Services
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
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.

36. Applies only to Inpatient, hospital based clinic, or ED
Shared Visit
Applies only to Inpatient, hospital based clinic, or ED
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.
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
Applies only to Inpatient or hospital based clinic or ED

37. Special Thanks Aditee Narayan, MD and Katy Bartlett, MD
Office of Graduate Medical Education
Jessica Ferrari, Department of Pediatrics Revenue Manager
Danielle Davis, Department of Pediatrics Revenue Manager
Neil Kinard, Director, PDC Compliance Office
Aditee Narayan, MD and Katy Bartlett, MD
Lily Bartlett and Sam Ostrovsky, child actors

38. References