1. Data Quality Management: Coding Audit Lt Col Jeanne Yoder Uniform Business Office (a.k.a. Billing) 7 June 2005

2. Overview The Audit Coding

3. The Process Table Builds –Provider in correct MEPRS Clinic, with correct provider specialty code… Appointment = Revenue Code (a.k.a MEPRS) and institutional component identification, provider identification, appointment type (access to care) Appointment selects correct PATCAT Appointment marked as “Kept” Patient services Documentation Coding Data Input Audit Feedback, correct ambulatory data record/inpatient data record Re-audit

4. What the Audit Doesn’t Tell If the MEPRS was incorrect –e.g., in GYN instead of OB If the provider was incorrect –e.g., appointment with Dr A who was sick so seen by Dr B Injury/accident related Additional providers PATCAT

5. Audit is For: % of records available for audit % of Evaluation and Management (E&M) codes deemed correct % of International Classification of Diseases, 9 revision, Clinical Modifications (ICD-9-CM) codes deemed correct % of Current Procedural Terminology (CPT) codes other than those in the 99201-99499 range, and Healthcare Common Procedure Coding System (HCPCS) codes deemed correct

6. What DQMC sees I can tell we need to help this base #5#6a#6b#6c#6d#6e#7a#7b#7c#7d 90%60%11%53%66%100% 90%60%11%53%66%100%

7. What about these bases? #6b#6c#6d 60%67%66% 96%97% 93%64%97% 84%74%70% 76%77%38% 66%60%51% 67%54%84% 96%91%95% 51%60%19% 95%84%98% 81%92%91% 41%61%40%

8. 6a. Outcome of monthly outpatient coding audit: Percentage of outpatient medical records on-hand or documented as checked out? 6aDec 04Jan 05Feb 05 SEOUL97%100%97% HEIDELBERG100% 99% LANDSTUHL99%100% WUERZBURG96%90%87% FT. BLISS97%100% FT. CARSON100% FT. HOOD74%100%71% FT. HUACHUCA97%100% FT. LEAVENWORTH100% 88% FT. LEONARD WOOD100% FT. POLK97%99%95% FT. RILEY100% FT. SAM HOUSTON100%47%92% FT. SILL100% FT. BELVOIR96% FT. BRAGG100% FT. DRUM100% FT. EUSTIS100% FT. KNOX100% FT. LEE96%95%97% FT. MEADE95%100%96% FT. MONMOUTH100% WALTER REED100% WEST POINT100% TAMC99%100%98% JAPAN100% FT. BENNING100% FT. CAMPBELL100% FT. GORDON100% FT. JACKSON93%96%100% FT. RUCKER100% FT. STEWART100% REDSTONE ARSENAL100% FT. IRWIN100% FT. LEWIS100% FT. WAINWRIGHT86%93%100%

9. 6a. Outcome of monthly outpatient coding audit: Percentage of outpatient medical records on-hand or documented as checked out? Feb-056a % NH Pensacola60% NH Jacksonville100% NH Corpus Christi93% NH Sigonella97% NHC London95% NH Beaufort76% NH Guantanamo Bay100% NH Naples96% NH Rota87% NH Charleston99% NH Keflavik98% NHC Annapolis100% NNMC Bethesda96% NMC Portsmouth100% NH Great Lakes100% NHC Quantico100% NHC New England85% NH Cherry Point100% NHC Pax River94% NH Camp Lejeune91% NMC San Diego98% NH Twenty Nine Palms99% NH Lemoore100% NH Oak Harbor100% NH Camp Pendleton100% NH Bremerton100% NH Guam99% NHC Hawaii93% NH Yokosuka100% NH Okinawa100%

10. 6a. Outcome of monthly outpatient coding audit: Percentage of outpatient medical records on-hand or documented as checked out? Feb 056a Bolling86 Barksdale0 Beale98 Cannon94 DM62 Dyess89 Ellsworth100 Holloman80 Langley100 Minot93 Mt Home95 Nellis99 Offutt100 Sey-John58 Shaw96 Whiteman89 Altus94 Columbus97 Goodfellow73 Keesler75 Lackland68 Laughlin72 Little Rock86 Luke95 Maxwell81 Randolph99 Sheppard96 Tyndall98 Vance100 Buckley0 FE Warren100 LA78 Malmstrom97 Peterson100 Patrick84 Vandenberg90 Hurlburt89 Moody99 Brooks100 Edwards85 Eglin42 Hanscom100 Hill99 Kirtland82 Robins82 Tinker100 W Pat100 Andrews88 Charleston96 Dover92 Fairchild80 Grand Forks97 MacDill95 McCord92 McConnell79 McGuire100 Pope95 Scott69 Travis34 Andersen89 Eielson97 Elmendorf97 Hickam100 Kadena100 Kunsan100 Misawa0 Osan0 Yokota95 USAFA93 Aviano99 Incirlik95 Lakenheath94 Ramstein100 Spangdahlem88 Lajes100

11. 6a Why the variation –Is this a random audit? –Are ALL SADRs for the MTF included Technicians/nurses Telephone calls ALL MEPRS (include FBI) –What qualifies as “checked-out” – in the past week, past month, past year, past decade? What do the data tell us?

12. What do foot notes say? Item 6a (From our Medical Records NCO): The Optometry clinic had been holding on to records for several days at a time in November, but they were reminded that the medical records must be returned to the records section ASAP.

13. Just Asking Where are the data for the record room at Di Lorenzo Clinic at the Pentagon?

14. Who needs my help? 6b. Outpatient coding audit: % E&M correct? May-04Jun-04Jul-04 Mar-04Apr-04May-04 96% 74% 78% 72%66%70% 85%93%84% 96%99%97% 98%74% 91%100%78% 95%97%95% 96%100% 98%67%51% 83%98%100% 89%87%91% 75%50%55% 100%95%97%

15. 6b. Outcome of monthly outpatient coding audit: What is the percentage of E&M codes deemed correct? SEOUL74 HEIDELBERG83 LANDSTUHL73 WUERZBURG77 FT. BLISS100 FT. CARSON98 FT. HOOD100 FT. HUACHUCA94 FT. LEAVENWORTH89 FT. LEONARD WOOD42 FT. POLK100 FT. RILEY100 FT. SAM HOUSTON83 FT. SILL98 FT. BELVOIR94 FT. BRAGG77 FT. DRUM95 FT. EUSTIS78 FT. KNOX98.5 FT. LEE75 FT. MEADE93 FT. MONMOUTH87 WALTER REED66 WEST POINT77 TAMC97 JAPAN100 FT. BENNING67 FT. CAMPBELL76 FT. GORDON42 FT. JACKSON94 FT. RUCKER97 FT. STEWART88 REDSTONE ARSENAL61 FT. IRWIN86 FT. LEWIS78 FT. WAINWRIGHT47

16. 6b. Outcome of monthly outpatient coding audit: What is the percentage of E&M codes deemed correct? NH Pensacola97.2% NH Jacksonville100.0% NH Corpus Christi99.7% NH Sigonella100.0% NHC London99.9% NH Beaufort100.0% NH Guantanamo Bay99.9% NH Naples98.6% NH Rota95.7% NH Charleston99.0% NH Keflavik100.0% NHC Annapolis100.0% NNMC Bethesda98.0% NMC Portsmouth99.5% NH Great Lakes99.4% NHC Quantico99.9% NHC New England99.0% NH Cherry Point84.0% NHC Pax River99.5% NH Camp Lejeune99.2% NMC San Diego99.0% NH Twenty Nine Palms99.0% NH Lemoore99.0% NH Oak Harbor98.0% NH Camp Pendleton99.0% NH Bremerton99.0% NH Guam99.3% NHC Hawaii99.6% NH Yokosuka99.9% NH Okinawa96.0%

17. 6b. Outcome of monthly outpatient coding audit: What is the percentage of E&M codes deemed correct? Feb 056b Bolling76 Barksdale0 Beale97 Cannon98 DM69 Dyess97 Ellsworth100 Holloman59 Langley80 Minot99 Mt Home86 Nellis96 Offutt96 Sey-John76 Shaw96 Whiteman62 Altus93 Columbus90 Goodfellow71 Keesler95 Lackland88 Laughlin92 Little Rock93 Luke88 Maxwell90 Randolph100 Sheppard90 Tyndall100 Vance96 Buckley0 FE Warren100 LA83 Malmstrom73 Peterson100 Patrick70 Vandenberg0 Hurlburt83 Moody99 Brooks87 Edwards96 Eglin91 Hanscom97 Hill100 Kirtland88 Robins95 Tinker86 W Pat95 Andrews89 Charleston100 Dover92 Fairchild78 Grand Forks85 MacDill94 McCord91 McConnell48 McGuire56 Pope98 Scott67 Travis80 Andersen68 Eielson96 Elmendorf93 Hickam85 Kadena80 Kunsan98 Misawa0 Osan0 Yokota91 USAFA64 Aviano74 Incirlik88 Lakenheath76 Ramstein99 Spangdahlem88 Lajes100

18. 6c. Outcome of monthly outpatient coding audit: What is the percentage of ICD-9 codes deemed correct? SEOUL70 ERMC83 HEIDELBERG82 LANDSTUHL78 WUERZBURG89 GPRMC89 FT. BLISS97 FT. CARSON87 FT. HOOD99 FT. HUACHUCA92 FT. LEAVENWORTH85 FT. LEONARD WOOD42 FT. POLK100 FT. RILEY100 FT. SAM HOUSTON87 FT. SILL100 NARMC84 FT. BELVOIR100 FT. BRAGG68 FT. DRUM90 FT. EUSTIS63 FT. KNOX97 FT. LEE85 FT. MEADE93 FT. MONMOUTH97 WALTER REED91 WEST POINT57 PRMC64 TAMC37 JAPAN90 SERMC84 FT. BENNING79 FT. CAMPBELL79 FT. GORDON73 FT. JACKSON97 FT. RUCKER96 FT. STEWART77 REDSTONE ARSENAL87 WRMC66 FT. IRWIN90 FT. LEWIS88 FT. WAINWRIGHT20

19. 6c. Outcome of monthly outpatient coding audit: What is the percentage of ICD-9 codes deemed correct? NH Pensacola55% NH Jacksonville97% NH Corpus Christi83% NH Sigonella100% NHC London85% NH Beaufort86% NH Guantanamo Bay82% NH Naples80% NH Rota90% NH Charleston66% NH Keflavik100% NHC Annapolis77% NNMC Bethesda84% NMC Portsmouth60% NH Great Lakes93% NHC Quantico84% NHC New England70% NH Cherry Point47% NHC Pax River44% NH Camp Lejeune69% NMC San Diego71% NH Twenty Nine Palms27% NH Lemoore98% NH Oak Harbor83% NH Camp Pendleton72% NH Bremerton100% NH Guam100% NHC Hawaii80% NH Yokosuka83% NH Okinawa100%

20. 6c. Outcome of monthly outpatient coding audit: What is the percentage of ICD-9 codes deemed correct? Bolling45 Barksdale0 Beale99 Cannon91 DM58 Dyess93 Ellsworth94 Holloman59 Langley83 Minot88 Mt Home79 Nellis96 Offutt94 Sey-John88 Shaw77 Whiteman64 Altus91 Columbus91 Goodfellow85 Keesler87 Lackland70 Laughlin97 Little Rock97 Luke80 Maxwell98 Randolph99 Sheppard80 Tyndall94 Vance95 Buckley0 FE Warren98 LA88 Malmstrom75 Peterson100 Patrick62 Vandenberg0 Hurlburt69 Moody69 Brooks74 Edwards94 Eglin81 Hanscom99 Hill88 Kirtland82 Robins93 Tinker78 W Pat95 Andrews67 Charleston99 Dover91 Fairchild73 Grand Forks71 MacDill77 McCord90 McConnell56 McGuire53 Pope97 Scott71 Travis35 Andersen72 Eielson82 Elmendorf93 Hickam83 Kadena73 Kunsan90 Misawa0 Osan0 Yokota84 USAFA72 Aviano73 Incirlik62 Lakenheath55 Ramstein47 Spangdahlem76 Lajes85

21. 6d. Outcome of monthly outpatient coding audit: What percentage of CPT codes deemed correct? SEOUL96 HEIDELBERG96 LANDSTUHL96 WUERZBURG89 FT. BLISS97 FT. CARSON99 FT. HOOD98 FT. HUACHUCA98 FT. LEAVENWORTH93 FT. LEONARD WOOD48 FT. POLK100 FT. RILEY100 FT. SAM HOUSTON80 FT. SILL100 FT. BELVOIR100 FT. BRAGG93 FT. DRUM96 FT. EUSTIS100 FT. KNOX99 FT. LEE98 FT. MEADE97 FT. MONMOUTH100 WALTER REED97 WEST POINT83 TAMC97 JAPAN97 FT. BENNING90 FT. CAMPBELL97 FT. GORDON83 FT. JACKSON96 FT. RUCKER100 FT. STEWART73 REDSTONE ARSENAL71 FT. IRWIN93 FT. LEWIS97 FT. WAINWRIGHT30

22. 6d. Outcome of monthly outpatient coding audit: What percentage of CPT codes deemed correct? NH Pensacola74% NH Jacksonville97% NH Corpus Christi94% NH Sigonella97% NHC London86% NH Beaufort59% NH Guantanamo Bay90% NH Naples88% NH Rota91% NH Charleston80% NH Keflavik100% NHC Annapolis90% NNMC Bethesda40% NMC Portsmouth87% NH Great Lakes95% NHC Quantico100% NHC New England94% NH Cherry Point33% NHC Pax River70% NH Camp Lejeune86% NMC San Diego80% NH Twenty Nine Palms70% NH Lemoore100% NH Oak Harbor97% NH Camp Pendleton81% NH Bremerton78% NH Guam100% NHC Hawaii95% NH Yokosuka100% NH Okinawa100%

23. 6d. Outcome of monthly outpatient coding audit: What percentage of CPT codes deemed correct? Bolling50 Barksdale0 Beale98 Cannon99 DM89 Dyess98 Ellsworth88 Holloman86 Langley96 Minot84 Mt Home76 Nellis93 Offutt91 Sey-John100 Shaw87 Whiteman49 Altus85 Columbus95 Goodfellow85 Keesler95 Lackland87 Laughlin86 Little Rock96 Luke80 Maxwell97 Randolph96 Sheppard71 Tyndall90 Vance86 Buckley0 FE Warren94 LA99 Malmstrom70 Peterson79 Patrick97 Vandenberg0 Hurlburt98 Moody82 Brooks79 Edwards96 Eglin91 Hanscom100 Hill88 Kirtland87 Robins85 Tinker86 W Pat100 Andrews81 Charleston96 Dover93 Fairchild58 Grand Forks59 MacDill95 McCord84 McConnell73 McGuire48 Pope99 Scott78 Travis100 Andersen92 Eielson84 Elmendorf92 Hickam90 Kadena90 Kunsan100 Misawa0 Osan0 Yokota85 USAFA87 Aviano76 Incirlik46 Lakenheath34 Ramstein86 Spangdahlem44 Lajes62

24. 6e. What percentage of completed & current DD Form 2569s are maintained in the record? SEOUL97 HEIDELBERG60 LANDSTUHL93 WUERZBURG64 FT. BLISS80 FT. CARSON95 FT. HOOD72 FT. HUACHUCA69 FT. LEAVENWORTH63 FT. LEONARD WOOD76 FT. POLK60 FT. RILEY100 FT. SAM HOUSTON58 FT. SILL64 FT. BELVOIR97 FT. BRAGG45 FT. DRUM84 FT. EUSTIS70 FT. KNOX71 FT. LEE81 FT. MEADE73 FT. MONMOUTH68 WALTER REED100 WEST POINT100 TAMC57 JAPAN97 FT. BENNING60 FT. CAMPBELL98 FT. GORDON65 FT. JACKSON40 FT. RUCKER71 FT. STEWART60 REDSTONE ARSENAL73 FT. IRWIN79 FT. LEWIS28 FT. WAINWRIGHT97

25. 6e. What percentage of completed & current DD Form 2569s are maintained in the record? NH Pensacola26% NH Jacksonville44% NH Corpus Christi80% NH Sigonella NHC London NH Beaufort14% NH Guantanamo Bay NH Naples NH Rota NH Charleston0% NH Keflavik NHC Annapolis0% NNMC Bethesda30% NMC Portsmouth28% NH Great Lakes0% NHC Quantico13% NHC New England88% NH Cherry Point88% NHC Pax River23% NH Camp Lejeune50% NMC San Diego4% NH Twenty Nine Palms57% NH Lemoore83% NH Oak Harbor90% NH Camp Pendleton100% NH Bremerton70% NH Guam93% NHC Hawaii53% NH Yokosuka NH Okinawa

26. 6e. What percentage of completed & current DD Form 2569s are maintained in the record? Feb 056e Bolling94 Barksdale0 Beale82 Cannon62 DM83 Dyess87 Ellsworth57 Holloman45 Langley71 Minot99 Mt Home91 Nellis86 Offutt52 Sey-John64 Shaw50 Whiteman81 Altus98 Columbus77 Goodfellow66 Keesler52 Lackland79 Laughlin91 Little Rock73 Luke83 Maxwell61 Randolph71 Sheppard79 Tyndall90 Vance100 Buckley50 FE Warren100 LA63 Malmstrom23 Peterson64 Patrick77 Vandenberg90 Hurlburt89 Pope34 Scott68 Travis75 Andersen10 Eielson93 Elmendorf71 Hickam87 Kadena100 Kunsan0 Misawa0 Osan0 Yokota0 USAFA59 Aviano38 Incirlik17 Lakenheath9 Ramstein6 Spangdahlem59 Lajes4 Moody100 Brooks75 Edwards56 Eglin61 Hanscom47 Hill76 Kirtland77 Robins92 Tinker71 W Pat90 Andrews93 Charleston20 Dover43 Fairchild51 Grand Forks91 MacDill23 McCord81 McConnell73 McGuire0

27. Who needs help? 6b E&M May 20046c ICD May 2004 6d Procedure May 2004 %% 73%50%70% 100%97% 91%95%96% 73%83%97% 81% 80% 78%93%80% 89%84%92% 100%90%81% 54%96%83% 77%80%100% 83%93%100% 75%64% 85%97%96% 54%30%63% 99%95%96% 100% 94%95%96%

28. Bottom Line – Just Jeanne’s Thoughts When I see a 100% correct in professional services coding I suspect a problem at that base –Is the auditor also the coder? –Is the record pull random? –Do they have a clue about what they are doing?

29. The Audit Why - to verify the reliability of the data submitted in the SADR and SIDR feeds as well as the data stored on the local server –The results need to be reproducible. –Can you make decisions based on the data? –You give me bad data, I’ll make bad decisions.

30. The Audit Why – to identify strengths and areas for improvement –How big is the problem? –Which section is doing well – and why? –What resources will you need to put against the problem? –Can you borrow resources from the sections with better coding?

31. Cost of Bad Audit Why waste your resources doing a bad audit? –Your MTF’s decision makers have an unjustified cause to rely on your data –It takes one full-time-equivalent eight hours to print out charge out cards, make charge out files, pull records, scan out records, deliver, pick up, scan in, and refile 200 records –Providers think their coding is fine

32. Attributes of a Good Audit Random or targeted Reproducible Statistically significant (large enough) It tells you what you were trying to figure out It tells you how to best use your resources

33. Theory of Coding Jeanne’s Theory of Coding A person will code in the same manner he has always coded unless acted upon by an outside force. Jeanne’s Change Corollary Audits without feedback and training will produce no change in documentation or coding.

34. Random or Targeted How you select the encounters makes a difference –Always pick the 2 nd Tuesday Surgery day in Ortho (no outpt, only APVs) OB day in Women’s Health PA Fred helps out in the HAWC –Only records kept at your MTF Miss most consults and referrals Won’t know if you will have documentation to support billing

35. Random or Targeted How you select the encounters makes a difference –Only “Count” Miss all tech and nurse visits, as well as most “A” and “D” and “F” MEPRS –Only “B” MEPRS Miss “A” “D” “F” MEPRS –To Small Miss IDMTs, IDCs, circuit riders, providers not assigned to the MTF

36. Random or Targeted Look at your aggregate data –By code Any anesthesia codes (0xxxx) anywhere but DFAA Any radiology (7xxxx) or laboratory (8xxxx) codes anywhere but MEPRS DCxx and DBxx –There will be some Clinical Laboratory Improvement Act (CLIA) ones, your coders will recognize. –Look for chest x-rays in ER or MRIs in Family Practice…

37. Random or Targeted Look at your aggregate data –By MEPRS Usually don’t find vasectomies in Orthopedics, deliveries in Urology, abdominoplasty (tummy tuck) or “excision of excess skin” in Family Practice Easy to spot questionable procedures and E&M

38. Random or Targeted Those with the most risk –Other Health Insurance –Patients NOT empanelled to your MTF –Providers new to facility –Providers with history of coding issues –High dollar/high Relative Value Units (e.g., cardiac cath, APV) –Uncommon codes (e.g., 99205, 99215, 99244/5, 99284/5)

39. Random or Targeted Codes in Unexpected Places –E&Ms in mental health, PT/OT, optometry –99199 anywhere but in B**5 or B**7 –ER codes anywhere but the ER –Mental health codes anywhere but mental health (might have some in Family Practice if you have a social worker there) –Inpatient only procedures coded in the clinics –Really high Relative Value Units in the clinics

40. Reproducible If you follow the same selection criteria (with different random numbers), and the same evaluation criteria, the results should be similar

41. Statistically Significant Table for Values for n Desired Precision 95% Confidence Estimated % ±1% ±2% ±3% ±4% ±5% ±6% 2 or 92760190 5 or 95183046021011473 10 or 903460870390220 139 96 25 or 7572101800800450290200 40 or 60922023101030580370260 50960024001070610390270

42. What are you Trying to Figure Out? Does my MTF have quality data? If not, to what level should I trust my data? Where are big problems that will take minimal resources to fix?

43. What is the best way to use your resources? Pull only as many records as you can use that day – keeps the clinics from looking for checked out records Have the auditor check for everything at once –Summary sheet –DD Form 2569 –Documentation includes: legible, signed, dated, name of clinic, name of provider –Coding –Documents in correct location in record –Only that patient’s data in the record

44. “Charged Out” Charged out within the past week if still assigned to your MTF Patient PCSed and took record with If not assigned, but did services, the MTF MUST have a copy of the documentation available (even if the original goes in the medical record back to the patient’s MTF)

45. Last Thoughts You need to audit xxx charts –That means, audit, not pull –If you average 50% available, request twice as many as you need –Chart available – if it has been checked out for more than 7 days… get real, do you really consider that chart available? Do you really think it is coming back without your intervention? –Documentation present

46. Coding Overview ICD-9-CM CPT –Evaluation and Management –Procedures –Lab, Rad, Medicine, Anesthesia HCPCS –Ambulance, Durable Supplies…

47. Data Disposition MEPRS (APV,clinic,inpt) Patient Provider Labs Drugs Dispensed Rads Clinic Use Only Diagnoses Factors influencing health Causes of Injury Documentation Durable supplies, Drugs, Equipment, Dental (w/modifiers & quantity) E&M Procedures (with modifiers & quantity) (HCPCS) CHCS (ICD-9-CM) RVUs + CMAC, professional svs CODING PICTURE – What can be collected. (CPT) Additional Provider Ambulatory Data Module (ADM) Count

48. What may we code? Code ONLY what is documented –Need legible, complete documentation Code significant medical interventions –Document things like calling back lab results, but if just giving results, no need to code Code what is important to YOUR facility/service –HEDIS/other metrics –Billable Code to the level YOUR facility/service needs

49. ICD-9-CM International Classification of Diseases – 9 th revision- Clinical Modifications Epidemiology system written by World Health Organization Outpatient uses volumes 1 and 2 (alphabetic and tabular) Inpatient uses volumes 1, 2 and 3 (3 is inpatient procedures) ICD-10

50. ICD-9-CM International Classification of Diseases – 9 th revision-Clinical Modifications Inpatient institutional reimbursement based on these codes to form the Diagnosis Related Group (DRG) –Relative Weighted Product (RWP) is an INSTITUTIONAL weight – has no relationship to an RVU which is a professional service weight Outpatient uses to show medical necessity Used for: –Population Health –Clinical Quality

51. ICD-9 Field Use codes in ICD-9-CM –Diagnosis ### or ###.# or ###.## or ###.## # –V-Codes V##.# or V##.## –E-Codes E### or E###.# Used to tell the story of the visit –Indicates medical necessity –Supports billing for outpatient coding Used to determine inpatient facility reimbursement (diagnoses plus inpatient procedures generate the Diagnosis Related Group)

52. ICD-9 Field Diagnosis –Current conditions (don’t code resolved conditions) –Underlying conditions –Highest known level –AF - Code with “U” for “unconfirmed” to explain actions Factors Influencing Health –Well babies, physicals, screenings, hx of cancer, f/u visits, need for immunizations, counseling and education External Causes of Injury

53. ICD-9 Field If there are only three numbers “XXX” (only 96 dx), you may code only three numbers –460 Cold If there are four possible numbers”XXX.X”, you must code four numbers –599.0 UTI If there are five possible numbers”XXX.XX”, you must code five numbers –250.00 DM, NOS If there are DoD extender codes, you must use one of them –V70.5_ _ 6 Post deployment exam (for problems related to deployments)

54. ICD-9 Field in ADM 1, 2, 3, 4, U –1 – primary diagnosis, diagnosis/condition that most closely matches why the person came in –2 – second condition treated or underlying cause –3 and 4 – up to provider, if extensive time spent counseling (not just “You should exercise more”) –U – unconfirmed (for the AF), not used by Navy or Army If you type in more than 4, those without 1/2/3/4 will get a U Must assign number of procedure to match the number of the diagnosis (e.g., 1, 2, 3, 4) –OM does not match to remove impacted cerumen; Impacted cerumen matches to remove impacted cerumen

55. ICD-9 Field If you want to code to detailed level, you must teach your providers to document to that level Code to collect data to the level you will use/ need (Ask your Service for their needs)

56. Current Procedural Terminology (CPT) System developed to obtain reimbursement for inpatient and outpatient professional services Two coding systems –Evaluation and Management –Procedures Usually involve productivity Written by AMA Secret decoder – read “physician” as “provider” Used for staffing and budget

57. Current Procedural Terminology (CPT) A way to obtain reimbursement from insurance companies for work done in a group practice, both in the office and for work done in hospitals 0xxxx Anesthesia 1xxxx - 6xxxx Invasive Procedures 7xxxx Diagnostic Imaging/Radiation Oncology 8xxxx Lab 9xxxx Non-invasive Procedures (e.g., immunizations, mental health, optometry, neurology, cardio-pulmonary, OT, PT, nutritional medicine, osteopathic manipulations) 99201-99499 Evaluation and Management (types of encounters)

58. Current Procedural Terminology Evaluation and Mngt (E&M) Field Type of visit –Office (new and established) –Rounds/admit/discharge –Consult (outpatient, inpatient, confirmatory) –ER –Telephone consults –Physicals (new and established) –Group prevention –Special Eval and Mngt –No visit/procedure only (use code 99499) Not all specialties use the office visit E/M (Mental Health, PT/OT, Optometry/Ophthalmology, Nutritional Medicine)

59. Current Procedural Terminology Evaluation and Mngt (E&M) Field Currently starting collection of inpatient professional services –http://www.pasba.amedd.army.mil/CodingF rameset.html –http://tricare.osd.mil/org/pae/ubu/ Will now have ALL professional service workload, not just outpatient professional service –Easier to compare to civilian sector

60. Healthcare Common Procedure Coding System CPT/HCPCS Codes Field Developed as method for reimbursement from insurance companies for things furnished in a provider practice which are not professional services –Drugs, neck braces, crutches, ambulance runs Written by Centers for Medicare and Medicaid Services Usually involve cost, occasionally involve productivity Because it is such a dumping ground, has applications in staffing, budget, population health, clinical quality X#### (format is letter with 4 numbers and no decimal point)

61. Current Procedural Terminology Procedure Codes CPT/HCPCS Codes Field Procedures –Only code those done and interpreted in the clinic (usually not diagnostic imaging [7xxxx] and not laboratory [8xxxx] codes) –Must be explained by the diagnosis codes –Must be done at the most appropriate level –“Money makers” in the civilian sector – earn Relative Value Units (RVUs) –Understand difference between office procedures (do not need post operative medical supervision) and Ambulatory Procedure Visits

62. Healthcare Common Procedure Coding System CPT/HCPCS Codes Field Healthcare Common Procedure Coding System –Will impact accrual fund for TRICARE Senior Prime –Very important for Third Party Collection/ Outpatient Itemized Billing (OIB) –Codes for durable supplies (e.g., crutches, orthotics), drugs (clinic stock), ambulance services (vehicle and tech portion) –Do not code for drugs issued by the pharmacy –Do not code for supplies that will be returned (e.g., CPAP machine)

63. Questions