coding basics don’t make it harder than it has to be

Coding BasicsDon’t make it harder than it has to be.

History of ICD-9

Originated in England during the 1700’s

Called the “London Bills of Mortality”

In 1930’s, morphed into the “International List of Causes of Death”

Fahoum copyright 2012

History of ICD-9

1948, the World Health Organization (WHO) developed the International Classification of Disease (ICD)

Goal was to create a tool to track morbidity and mortality

1977 the 9th edition was published, hence ICD-9.

Newer versions are ICD-9-CM (even more clinical modifications)


ICD-10, that’s what I need to know!!

ICD-10 transition is set for October 2014. The US is one of the last countries to make the move.

You will need to understand and know how to apply ICD-9 well to make the transition easier.

Because….ICD-10 is more complicated, six-digit, alpha-numeric system.

Specify laterality, new, follow-up, chronic, improved, worsened, So much more detail!

ICD-9 = Reimbursement

Code what you see the patient for, and chart what you saw. In other words:

Do what is medically necessary, completely document what you do and accurately code what you documented.


To the Codes…

Steps to proper diagnostic coding:

1. Code the chief reason or most acute condition as the primary (#1) diagnosis.

2. Use the alphabetical and tabular lists to get to the MOST specific code possible.

Just like a homeopathic repertory…


For example

Patient comes in with an annoying wart, but you find they have a a BP of 180/110 with a headache. Chief complaint PPR was a wart, but your coding is going to place

the hypertensive reading in the #1 slot, then the headache, then the wart.


Example, cont.

You also need to get to the most specific ICD-9 code: If this patient has no prior hypertension then Blood, pressure, high,

incidental reading, without diagnosis of hypertension or 796.2 is the code vs.

Prior HTN would give you 401.9, for HTN(uncontrolled)(fluctuating)(systemic)


Example, cont.

Then I would code the headache, which is a symptom of the HTN: Headache, or Headache, vascular, both have code 784.0

Last would be the wart: Wart, common 078.19 Would I treat the wart today?


Another example

You have to get to the most specific code: this may only be 3 digits, 4 digits or the most specific 5 digits. (ICD-10 is 6 digits)

Coryza = 460

Cough = 786.2

Abd pain, LUQ = 789.02 (789.0 gets you to Abd pain, the 2, gives the LUQ)


Let’s look at this a little deeper 460=Acute nasopharyngitis [common cold]

Coryza (acute), Nasal catarrh, acute Nasopharyngitis: NOS, acute, infective NOS Rhinitis: acute, infective EXCLUDES: nasopharyngitis, chronic (472.2)

Pharyngitis: acute/NOS (462), chronic (472.1) Rhinitis: allergic (477.0-477.9), chr/NOS (472.0) Sore throat: acute/NOS (462), chronic (472.1)


Let’s look at this a little deeper

786.2 = Cough EXCLUDES cough:

Psychogenic (306.1) Smokers’ (491.0) With hemorrhage (786.39)


Let’s look at this a little deeper

789 Other symptoms involving the abdomen or pelvis, EXCLUDES symptoms referable to genital organs. 789.0 Abdominal Pain 0 unspecified site 5 periumbilic 1 RUQ 6 epigastric 2 LUQ 7 generalized 3 RLQ 9 other specified site 4 LLQ multiple sites


Next bit of detail…

You now know you are going to code them from most important (or acute) to least, and you’re going to code to the highest specificity, now…

You can only use a code once per visit (so bilateral issues, need to be charted)

You have four spaces, so use them, IF YOUR CHART NOTES SUPPORT IT!!


More Guidelines

Signs and symptoms: Codes that describe symptoms and signs, as opposed to diagnoses are acceptable for reporting when a definitive diagnosis has not been established (or confirmed) by the provider.

Headache (784.0) vs. Classical migraine without mention of intractable migraine (346.01)

Or, diarrhea, infectious, presumed (009.3) vs. diarrhea, due to, Staphylococcus (008.41)


More Guidelines

You cannot code items that are already associated with a coded condition. Premenstrual syndrome (625.4), don’t add

cramps, abd pain, bloating…it’s implied in primary code.

Do code items that are not part of the stated condition. PMS, but they also have constipation and abd

pain not related to their cycle.


More Guidelines

Manifestations of one disease process, are secondary to the primary condition.

For example: Peripheral neuropathy and a leg ulcer in a diabetic patient1. DM w/ neuro manifestations, controlled (250.60)

2. Polyneuropathy (357.2)

3. Ulcer, skin, lower extremity, calf (707.12)


More Guidelines

If you have an acute exacerbation of a chronic condition and you are seeing them for both today:

The acute code is #1, followed by the chronic code

Example: Acute maxillary sinusitis (461.0) in a person who suffers from chronic sinustis (473.9)


General vs. Specific

Can be a red flag for insurance companies: Neck pain (723.1) every visit for the next two years says your

treatments aren’t very effective Low back pain (724.2) vs. Degeneration of lumbar intervetebral

disc (722.52), if you have a diagnosis, use it!!


V codes

Love ‘em, but you have to know how to use them!

“Supplementary Calssification of Factors Influencing Health Status and Contact with Health Services”

Translation = exposures to illness, history of illnesses, physicals, counseling, congenital issues, screenings, outside factors in general


V codes

V70, most common v-code for annual exams and physicals V70.0 Routine general medical exam at a healthcare facility V70.3 other medical exam for admin

Camp, school admission, sports, insurance, etc V70.5 Health exams of defined subpopulations (armed forces, pre-

employment, etc.)


V code Guidelines

If ANNUAL is to be applied to an individual’s preventive insurance benefit (which is usually pre-deductible), you MUST put it in the #1 slot on the billing form.

Other V codes are great, but be wary of putting the following codes in the #1 spot if you want to get paid…very few people have counseling or preventive service benefits outside their annual or possibly contraceptive care.


Examples

V72.32 Encounter for pap smear to confirm recent NL smear following initial ABNL smear

V72.40 Preg exam/test, preg unconfirmed

V25.01 Prescription of OCP

V25.04 Counseling in natural family planning to avoid pregnancy

MUST CHECK BENEFITS


More Examples

V65.3 Dietary surveillance and counseling

V65.42 Counseling on substance use and abuse

V65.45 Counseling on other STDs

V69.2 High-risk Sexual behavior

V01.89 Exposure to parasitic disease

V75.1 Screening malaria

For Next week, have a copy of the Audit Tool printed out for reference during webinar!!!!!


Putting it all Together for CPTMona Fahoum, ND


CPT Layout

Evaluation & Management 99201-99499

Anesthesiology 00100-01999

Surgery 10040-69979

Radiology 70000-79999

Pathology/Lab 80000-89399

Medicine 90701-99199


Evaluation & Management(E/M)

Codes 99201-99499

Designed to describe the service provided by the practitioner.

Both the ‘visit’ or evaluation, and the ‘treatment’ or management of the condition.

Also broken down by level of service and location (hospital vs. office)


Evaluation & Management(E/M)

Very good idea to read, read and re-read the coding guidelines at beginning of this section, pages 4-9.

If you sign a contract with an insurance company, you will be held to this system.

If you don’t sign a contract with an insurance company you will still be held to this system on some level.


CPT Guidelines Evaluation and Management Codes:

Consist of new patient visits and return visits

Take into account hpi, pfsh, ros, exam, time and complexity.

Components of each covered element during the visit add up to the code you use for the encounter.

CPT codes need to match ICD-9’s, which match your charting


E&M Codes

99201-99205, new patient medical visit

99211-99215, established patient visit

Also have Preventive visits in this category 99382-99387 (New patient preventive) 99392-99397 (established patient preventive)

-Make sure they have preventive benefits!!!


E&M Codes

Modifiers: add value to visit, we will cover later.

Bundling: Insurances like to combine codes and pay only one. Peak flow during a visit is bundled into visit.


CPT 99202

Office or other outpatient visit for the E/M of a new patient, requiring these 3 components: An expanded problem focused history An expanded problem focused exam Straightfoward medical decision making

Counseling and/or COC is consistent with the nature of the problem and the patient’s needs.

Usually, the presenting problem(s) are of low to moderate severity. Physician typically spends 20 minutes face-to-face with patient.


Versus a 99205

Office or other outpatient visit for the E/M of a new patient, requiring these 3 components: A comprehensive history A comprehensive exam Medical decision making of high complexity


Usually, the presenting problem(s) are of moderate to high severity. Physician typically spends 60 minutes face-to-face with patient.


CPT 99213

Office or other outpatient visit for the E/M of an established patient, requiring 2 of these 3 components: An expanded problem focused history An expanded problem focused exam Medical decision making of low complexity


Usually, the presenting problem(s) are of low to moderate severity. Physician typically spends 15 minutes face-to-face with patient.


Versus 99214

Office or other outpatient visit for the E/M of an established patient, requiring 2 of these 3 components: An detailed history An detailed exam medical decision making of moderate complexity


Usually, the presenting problem(s) are of moderate to high severity. Physician typically spends 25 minutes face-to-face with patient.


So what next?

We have to figure out what problem-focused means as compared to expanded, detailed and comprehensive.

We have to figure out what low-moderate and high severity look like.

We have to figure out what low-moderate and high complexity mean.

Grab your audit tool and fasten your seatbelt.


Subjective/Objective Section

Did you do HPI, how completely?

ROS, how many systems?

PFSH, how many areas?

PE, Count up your systems and areas

Chart what you do, pertinent positives, check off the negatives. GET VITALS!


Systems or Body Areas??

There are two ways to get your ‘points’ for physical exam.

1. Document at least two bullets from the specified number of systems, or

2. Document all bullets from a given area, plus at least one bullet from other pertinent areas/systems

Look at the chart notes from last week as an example, each check box is a ‘bullet’ from the official E/M guidelines.


Official Guidelines

Link to the official E/M guidelines, most recent version from 1997.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf


So, the audit tool

1. HPI, ROS and PFSH

2. Exam

3. MDM

For HPI and Exam let’s look at the differences between problem focused, detailed and comprehensive.


HPI/PE are relatively straight foward, but then we get to MDM. . .

The rest of this audit tool is our mechanism to working out our level of Medical Decision Making

More Precisely the Complexity and Severity of the case.


Number of Diagnoses

If you have four, use four ICD-9s.

Remember, it may be better to use only a couple and thoroughly work them up.

Let’s look at the table.


Amount or Complexity of Data

Records to review, consulting with another practitioner, labs, etc.

Another piece is Coordination of Care with other providers

The trick is you need to write this in your chart note, we often do it, but don’t document it.


Table of Complexity

Go to audit tool for descriptions of: Minimal Low Moderate High

This is all very grey, not black/white


Final Result of Complexity

Take points from Diagnoses section of tool and plug into line 1,

Plug final level of risk from Table of Complexity into line 2,

Put points from Data section into line 3, and we get to,

Decide final complexity based on result from each column.


Final Result of Complexity

Final Medical Decision Making will be:

The column where you have 2 of the 3 items, or

If one in each column, take the middle value


Putting it all together…

For a new patient: must have elements from all 3 areas, HPI, PE and MDM Decision will be based on each of these elements

and follows the same principle as the ‘Final Result of Complexity’ table.

For an established patient: only need to meet 2 of the 3: HPI, PE and MDM, so a little easier to get higher level, but beware…


And to help get you there:

Can use additional factors: Nature of presenting problem (not as important for us NDs) Counseling Coordination of Care Time


Nature of Presenting Problem

Nature of Presenting Problem:

Minimal: doesn’t require a physician to be present (ie. BP check) Self-limited: problem runs a definite and prescribed course with

no long-term sequelae Low severity: risk of morbidity without Tx is low and little to no

risk of morbidity/mortality Moderate severity: risk without Tx is moderate and there is a

moderate risk of morbidity/mortality w/o Tx. May also have an uncertain prognosis or increased probability of prolonged functional impairment.

High severity: Risk of morbidity w/o Tx is high, risk of mortality is high or there is a high probability of prolonged functional impairment.


Counseling and COC

Time spent in discussion with the patient, family or another physician concerning: Diagnostic results, impressions or recommended

studies Prognosis Risks and benefits of treatment options Instructions for management/follow-up Importance of compliance with chosen Tx Risk factor reduction Patient and family education


Time

THIS IS FACE-TO-FACE TIME ONLY

If more than 50% of visit is spent in counseling then you may code at one level higher or based on time.

Great if you’re in between levels, or need help justifying complexity.

A lot of controversy over this issue. It’s totally fine as long as you have met 2 of the 3 elements above in your charting!!


To the codes…

NEW Patients: Have not been seen by you or anyone in your office of the same specialty for more than three years. 99201-99205 10, 20, 30, 45 and 60 minutes typically

Established patients: Everyone else 99211-99215 5,10, 15, 25, and 40 minutes typically

BUT what did we say about time????


Consultations

99241-99245

Won’t be paid…

Medicare took out this year, so others will follow


Preventive medicine services

Includes a ‘check-in’ on chronic diseases, but if a new or acute condition or exacerbation is reported can use an E/M code in addition with modifier -25 (significant/separate E/M)

Broken down by ages New: 99381-99387 Established: 99391-99397



Prolonged service codes

Overused in our profession, and a flag for insurance companies.

Very legitimate codes, when used properly.

Now that we can use time for billing when >50% is in counseling, you really don’t need these so much if you have good time management skills.

If you do use them, you have to document the start and stop times of care in your notes.


Prolonged service codes

The definition of these codes is very clear that it is for face-to-face time spent ‘beyond the usual service’.

Therefore, if you spend 90 minutes with every patient, this is your usual service, not a special circumstance.

If the visit takes longer d/t Hx, exam or counseling/coc, then use a higher level E/M code, but

If it is taking longer d/t language barrier, multiple family members, hard of hearing or other prolonged service (ie asthma attack) then these are acceptable codes.

Approximately 5-10% of billings out of a given office.


Prolonged Service codes

99354 for the first extra 60 minutes of time spent with patient.

99355 for each additional 30 minutes spent w/ patient.

Get added on top of your E/M code.

For example, if someone comes in with an asthma attack, but is well handled, just needs to be observed, then you might do a 99214 with a 99354. Same thing if Grandma comes in and it takes a long time to describe the treatment to her, it might be a 99213 with a 99354.

But, if it is a regular office visit and you just spend a lot of time counseling, so this is purely based off time, then you have to meet the requirements of a 99215 time-wise before you add the prolonged service code on. Basically, it has to go at least 90 minutes, with 60 of that in counseling alone.

Coding Case #1

65-year-old white male who presents to clinic for refill on furosemide, which he takes for treatment of CHF. The patient states that he ran out of his medication three days ago and is concerned that he may be "headed for trouble." The patient watches his weight carefully and noted a 5-lb. weight gain over the last one week.


CHF, cont.

The patient denies any chest pain or pressure, shortness of breath, dyspnea on exertion or change in the condition of two-pillow orthopnea. He denies any headache, dizziness, nausea or vomiting. He denies any lower-extremity swelling.


CHF, cont.

Medications: furosemide 60 mg qd, potassium supplement 10 mEq qd, digoxin 0.125 mg qd, captopril 12.5 mg qd, aspirin 325 mg qd.

No known allergies.

Past medical history: CAD, CHF.

Social history: No tobacco or alcohol use.


CHF, cont.

Vital signs: BP 140/80 sitting, 138/85 standing; P80; R 14; T 98.7; Wt. 185# (baseline 180#)

General: Well-developed, well-nourished white male, pleasant and cooperative, in no acute distress. Mood is somewhat anxious.

HEENT: Conjunctivae: nonicteric; oropharynx: moist mucous membranes.

Neck: No JVD, no bruits.

Heart: Regular rate without murmur or S3.

Lungs: Breathing unlabored; clear to auscultation bilaterally, no wheezes or rales noted.

Abdomen: Nontender, nondistended, no hepatosplenomegaly.

Extremities: No cyanosis, clubbing or edema.


CHF, cont.

Labs: BUN 25; creatinine 1.0; sodium 138; potassium 4.2; chloride 101; bicarb 24.

Assesment: CHF-stable


CHF, cont.

Prescription for furosemide 60 mg qd, dispense 30 with two refills was written. Patient was encouraged to continue monitoring weight daily and to follow sodium restrictions as previously instructed. Patient was instructed to continue digoxin, potassium supplementation, captopril, aspirin; no refills needed at this time. Return to clinic for follow-up in one month, sooner if symptoms persist.


CHF, final

Remember, three key components: History, ROS/Exam, Medical decision

So: History is 99213 ROS/Exam is 99214 Medical decision is 99212

For ROCs:Final Code is 99213, Highest code that 2 of

the 3 components have in common


Case #2, Established patient


CC: F/U HTN

INTERVAL HISTORY: HTN is well controlled, patient is compliant with meds and working on diet/exercise. Hyerlipidemia is also stable per recent labs. Review of systems is negative for chest pain, shortness of breath, DOE, vision change, HA or edema in lower extremity.

Exam shows a BP 126/78, HR 76, RR 20. Patient appears well. Heart RRR, LUCTA, No edema in limbs b/l. Labs show a creatinine of 0.9, electrolytes are normal. LDL is 75.

IMPRESSION: Stable HTN and hyperlipidemia.

PLAN: No changes needed. Continue current meds. ROC in six months.

Case #2, htn/hyperlip

HPI: 99213

Exam: 99213

MDM: 99212

2 out of three, says final code is 99213

The most used code out there…


25 Y.O. Female FOC Subjective

CC1: Last few years, constant diarrhea, sharp pain, stool urgency, no accidents. No blood or mucus. Can get 'wiped out' after diarrhea. N, lots eructations, no reflux/ No V. Stomach pain can be with/without food, with/without immediate diarrhea (up to 2 hours of pain). Pain is low abd, after stool is all out (up to 3 BMs in an hour) then pain subsides. 3BMs QD, up to 5BM. No constipation. No gas.

No problems prior, could eat anything, spicy, etc. Now no spicy food, tried minimizing dairy, gf, but not completely so no symptom change.

H/O planned parenthood: Last pap 2010, wnl, No STD hx, G1P1A0. Menses reg, bleed 4-5 days, just stopped OCPs, cramping, but major mood swings.

H/O anemia, “everytime checked”. Last bloodwork at gastro in Edmonds, few months ago. Gluc wnl, all nl ppr.

Not on any medications or supplements currently.


25y.o. female, cont.

DIET HISTORY and SHx:B: eggs, tortilla, sour crm, tomato, onion, bacon. Hates Coffee, can't have straight milk, spicy foods

S: Pepsi and a red bull (can't make it through day without caffeine)

L: Pho or sandwich

D: soup/salad or salmon, potatoe, veggie

EtOH: couple drinks a week (wine), Water: 3-4 glasses

NS, Fish 1/wk, lots of meat (beef, pork, cxn), not a big fruit person.Has to eat every four hours, or feels nauseous/lightheaded

Falls asleep easily, getting 8 hours, hard to wake. Tosses all night, wake to urinate 2+/night since daughter.

Worrier by nature. Daughter, Finances, etc. Hard to let boyfirend support her while thinking about going back to school. Also worries about where next bathroom is.

PMHx: cesarean with daughter 2005, No other surgeries, No other hosp, no major illnesses. Healthy kid, may have adenoids out as kid (unsure), had tubes in ears.

PFHx: Sister has Crohns (24y.o., started at 15), no one else in family IBD. PGM colon cx. MGF MI at 49 y.o. Mom-HTN, Dad-hyperlip, but healthy. No DM.


25y.o. Female, cont.

ROS: General: No weight change, generally healthy, no change in strength, unable to exercise d/t diarrhea/fatigue. Head: No headaches, no vertigo, no injury. Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no obstruction, no discharge. Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Heart: No chest pains, no palpitations, no syncope, no orthopnea. GU: No urinary urgency, no dysuria, no change in nature of urine. Gyn: No change in menses, no dysmenorrheal, no vaginal discharge, no pelvic pain. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.

Objective: BP 112/70, HR 72, RR 12, Wt 135, Ht 54 inches

General: Normotensive, in no acute distress. Head: Normocephalic, no lesions. Eyes: PERRLA, EOM's full, conjunctivae pale. Nose: Mucosa normal, no obstruction. Neck: Supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales, no rhonchi, no wheezes. Heart: RR, no murmurs, no rubs, no gallops. Abdomen: Soft, no tenderness, no masses, BS normal. No organomegaly. Skin: Normal, no rashes, no lesions noted, capillary refill slow. Extremities: Cold, well perfused, no edema.


25y.o. female, cont. Assessment

1. Diarrhea 2. Abdominal Pain, unspec. 3. Nausea 4. Anemia

Plan: Spent 60 minutes with patients, 30 minutes in counseling around need to r/o Crohns. Pt unable to pay for colonoscopy as recommended by Gastro, so we decided on ASCA. I suspect that this is dietary related, we discussed high intake of sugar, possible dysbiosis, lack of dietary fiber and food intolerance. Pt. has strong desire for food allergy testing, and is unable to adhere to full Elimination diet. 1. Drew for ASCA, ferrritin, CBC, TSH, food allergies today.

2. Requested last labs from gastro at Krueger Clinic in Edmonds.

3. Increase water, veggies. Add an emergen-c to morning water.

4. Cut down on soda/redbull or at least chase with water. Consider tea instead.

5. Improve sleep. Melatonin 3mg qhs.

6. Hemaplex, 1 po qd

7. F/U 2 weeks.


Billing for this FOC

Component 1/History:HPI: Extensive (>4 elements)

ROS: Complete (>10 systems)

PFSH: Complete (>2 areas)

= 99204 or 99205

Component 2/Physical Exam:Comprehensive (general multi-system exam)

= 99204 or 99205


Billing for this FOC

Component 3/ Medical Decision Making:Decision making: moderate complexity (204)

# Dx/management options: multiple (204)

Amt/complexity of data: limited (203)

Risk/morbity/mortality: moderate (203)

Best two of three: HPI = 204 or 205

PE = 204 or 205

MDM = 203 or 204

Final CPT chosen is 99204, some may choose to do 99205, due to time and counseling, and could probably justify, but in reality, her risk and my level of intervention is not invasive or overly complex.


25 y.o. follow-up visit

Subjective Patient returns to follow-up for abd pain and diarrhea. She

started iron (hemaplex) and had more energy, but it constipated her a bit so she discontinued. Slowing down her BMs would have been a good thing, except with the pain, the only relief is the BM.

Since stopping the iron she has noticed good improvement just by implementing more veggies and lowering her sugar intake. She is still using energy drinks but found one with half the amount of sugar as red bull, she is also limiting other refined carbs. She has also done better with increasing her water to 30-40 oz.

BMs are now only two per day, less pain, but still very loose with some (but less) sense of urgency.

We review her labs, CBC, ferritin and ASCA testing all WNL. Food Allergies all negative.

No new medications No Change PFSH


25 y.o. follow-up

ROS:

General: No weight change, generally healthy, no change in strength or exercise tolerance.

Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Heart: No chest pains, no palpitations, no syncope, no orthopnea. Abdomen: No change in appetite, no dysphagia, no emesis, no melena. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.

Objective: BP 110/68, HR 68, Ht 54 inches, Wt 135

General: Normotensive, in no acute distress.

Head: Normocephalic, no lesions.

Eyes: PERRLA, EOM's full, conjunctivae clear.

Abdomen: Soft, no tenderness, no masses, BS normal.

Extremities: Warm, well perfused, no edema.


25y.o. follow-up

Assessment: Diarrhea, generalized Abd pain

Given negative testing for Crohn's at this point and negative food allergies, we are going to treat as inadequate fiber, suspected lactose intolerance and dysbiosis.

Plan:

Spent 30 minutes face to face with patient, 25 in counseling regarding labs, IgE vs. IgG allergy, lactose intolerance and dysbiosis. Given that she is already vastly improved with only one week of reducing sugars, she will continue that route dietarily, along with eliminating dairy for one month. Then we will test goat and sheep products, followed by cow.

1. Oregano oil 1 cap BID for 30D

2. HLC 2 caps QD x 30D

3. Continue to work to get the energy drinks switched out completely, or at least to only those sweetened with cane sugar.

4. Continue to increase water intake, veggie intake. Fiber handout given, with goal to get to 30g daily.


Billing for this ROC

Component 1/History:HPI: brief (1-3 elements)

ROS: ext (2-9 systems)

PFSH: pertinent (1 area)

= 99213 or 214

Component 2/Physical Exam:Limited for affected area + other related areas

= 99213


Billing for this ROC

Component 3/ Medical Decision Making:Decision making: low complexity (213)

# Dx/management options: limited (213)

Amt/complexity of data: multiple (214)

Risk/morbity/mortality: low (213)

Best two of three: HPI = 213 or 214

PE = 213

MDM = 213

Final CPT chosen is 99214, from the point system it is a 99213, but with the majority (>50%) in counseling, plus the time I spent (30 minutes) I get to bump it up one level.



Mona Fahoum, ND

Procedure and Physical Medicine Coding


Onward…

Office Management tips

Procedure codes (lavages, I&D’s, etc)

Physical Medicine Coding

Modifiers

Software review


Billing Ease…Relatively Stay on top of charting

Use superbill or fee slip, always create a paper trail

No matter how electronic your office is, you need a PAPER TRAIL.

Write legibly.

Sign and date EVERYTHING.

Document, document, document.


Common Errors

Wrong ID/group numbers

Wrong ‘insured’ information

CPT/ICD-9’s don’t match

Multiple visits on same day

Missing Diagnosis pointers

Always double-check before sending to catch the silly errors that hinder payment.


Tip of the Day

Know your services, Know what is billable…

Just because there is a code, doesn’t mean you can use it, and just because it got paid, doesn’t mean it’s right.

Unfair, but true.


Home Visits and Telephone Calls

Could try to bill, but won’t pay…

New patient: 99341-99345

Est. patient: 99347-99350 Payable, but probably not on our fee schedule,

reserved for disabled, nursing care, hospice mostly

Telephone calls: 99371-99373

Build these as cash services, have patients sign a non-covered service agreement.


Bundling

Term insurances use to mean that two services (or CPTs) are related and therefore, paid as one.

Best example is with a wound repair. Suture removal a week later is part of placing the sutures.

Another, Post-IUD placement, 30-day follow-up for string check is part of original insertion bill.

Another, doing a peak flow will get bundled into the E/M, it’s part of evaluating asthma.


Bundling

Less fair in physical medicine: Manual therapy is bundled into your Manipulation code

since it is assumed that some manual therapy is a part of the manipulation.

Not true, but that’s the way it is… Also, billing for hot packs will get bundled into the other

service you’re providing, will not get paid separately by medical insurance.


Procedure Codes

Generally pay well. Assumed that you have done evaluation appropriate to performing the procedure, therefore do not get an E/M for that visit in addition.

Unless… you see the person for two or more, ‘Significant & Separately identifiable Services. (modifier -25)


Procedure Codes

Most commonly used codes:

69210, Cerumen removal

10060, I & D of an abscess

11200, Skin tag removal (up to 15)

17110, Cryosurgery

90760, IV-hydration


Procedure Codes

All come with a description of the procedure so you need to read these.

For example:

10060 is ‘incision and drainage of abscess (carbuncle, suppurative hidradenitis, cut/subcu abscess, cyst, furuncle, or paronchyia), simple or single

If multiple then it changes to 10061, and if you didn’t actually use a scalpel and just did puncture aspiration of an abscess, hematoma, bulla or cyst its 10160.


Procedure Codes

Remember that many of these will get bundled into the E/M you are billing:

Peak flow, 94200 is a part of the management of asthma.

Anoscopy, 46600 is a part of evaluating hemorrhoids.

Sometimes have to do a little trial and error.


Laboratory Codes

Can only be done if completed in the office.

In Washington, must have a CLIA certificate to do in-office tests.

No modifiers needed, just go on another line on the CMS from.

Reimburse poorly, so use your time wisely.


Laboratory Codes

36415, Venipuncture

87880, Rapid Strep

86580, PPD insertion (includes read)

81002, UA dipstick

84703, Urine HcG

87210, Wet mount for infectious agents

87220, KOH prep (skin/hair/nails for fungi or ova/mites)


Laboratory Codes

May not pay much, but missed cash every time you don’t bill for what you do…

Anyone know how much a box of Rapid streps or a bottle of urine HcG tests are?


Physical Medicine Codes Hot topic and there is a lot of controversy and different opinions here.

I take a very literal approach, and encourage you to read these sections of the CPT book as you start using these codes.

Don’t just do what others do--that’s a very good way to do things erroneously.


Physical Medicine Codes

Codes 97010-97546, modalities and therapeutic procedures.

Codes 98925-98929, Osteopathic manipulation codes.

Not 98940-98943, chiropractic codes.


Physical Medicine Codes 97010, hot/cold packs, rarely paid because required no supervision by

practitioner.

97024, diathermy, also rarely paid, but can do both of these while doing something that does pay you.



Constant attendance codes, 97032-97039 and therapeutic procedures 97110-97140 are paid in 15 minute increments.

Iontophoresis, ultrasound, massage, neuromuscular reeducation, therapeutic exercise, manual therapy, etc.



REQUIRE face-to-face contact by provider, ie cannot have a staff person do it for you.

When billing need to be aware of time, there is some leaway, if you do 50 minutes you get to bill for 4 units (60 minutes)



Most common codes: 97110: Therapeutic exercise to 1 or more areas, each

15 minutes; exercises to develop strength and endurance, range of motion and flexibility.

97124: massage, including effleurage, petrissage and/or tapotement.

97140: manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.

97112: NM re-edu of mvmt, balance, coordination, posture and proprioception for sitting/standing



OMT codes are billed not on time, but on areas manipulated: 1-2, 3-4, 5-6, 7-8, 9-10 areas, each corresponds to a CPT code

Areas are: head, cervical, thoracic, lumbar, sacral, pelvic, lower extremities, upper extremities, rib cage, abdomen/viscera

Code set: 98925-98929



Here’s the controversy:

OMT codes include ‘preservice and postservice work associated with the procedure’. But, can use E/M with them if for a significant and separately identifiable service. (have to use a modifier to link them).

What does this mean?


OMT

Only use an E/M codes in conjunction with these codes if you are assessing a new problem, re-assessing an existing complaint periodically through treatment or are also seeing them for a ‘medical’ concern in addition to providing a physical medicine service on the same day (use -25 on E/M or -51 if another procedure).


Semantics Assessment is a part of any OMT, you don’t do

manipulation without evaluation.

If you are doing a re-vamp of your plan, then could use a brief E/M with your treatment, chart well.

If you are doing manual therapy with an OMT will get bundled…manipulation is part of definition of manual therapy, so double-dipping.


Semantics

However, NMT and Therapeutic exercise and massage do not have a manipulation component so you can bill the use of stretching/MES/etc. with OMT.

Have to understand definitions of these codes and/or, give a little manual therapy away…


Modifiers Because you can only see a patient once per day, if you do multiple

services then you have to ‘link’ them.

In other words, let the insurance company know that they need to consider a special circumstance in this visit and pay you more.


Modifiers

For example, in phys med: Patient comes in for a treatment, but also follow-up on HTN. You take a

quick history, med review, vitals, cardio exam, then do 45-minutes of Therapeutic exercise.

What CPT’s do we need?


Modifier -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

Effectively links the two services together, provided that you have charting on both pieces.


Modifier -25 Can use with OMT or phys med codes as in

example, or if you have to re-assess the same complaint (ie neck pain, or sciatica)

Can use if someone comes in with a sinus infection on the same day as their physical

Can use if you see someone for HTN and do a cerumen removal on the same day.

ALWAYS, gets attached to the E/M code.


Modifier -25

Can use with the same ICD-9 codes.

For example, a patient comes in with a headache, you take a history do an exam and end up treating them with a cervical adjustment.


Modifier -51

This modifier is used to show multiple procedures: Use it when you perform multiple procedures, other than E&M services, in the same session. For example, an ear lavage and a liquid nitrogen treatment on the same day/same visit. USE ON SECONDARY CODE, IT WILL OFTEN ONLY PAY AT 50%.

coding basics don’t make it harder than it has to be

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