Welcome to GAPHC 35th Annual Conference October 17-19, 2012

Transcription

1 Welcome to GAPHC 35th Annual Conference October 17-19,

2 2

3 Revenue Cycle: The Basics and Beyond 3

4 Presentation Overview Revenue Cycle Responsibilities of Medical Reception / Front Desk Documentation (in length) 4 Key Components -- MDM & Additional Components (Medical Necessity) Evaluation & Management Coding(in length) New vs Est. (what s required examples) Labs, HCPCS, HC, E-Codes, V-Codes, Modifiers, Combination Codes, Codes Commonly Overlooked, Coding Complex Pt s, Consultations, Higher Specificity Codes, Time Based, Vaccine Admin., Therapeutic Coding, and Coding TPI Touch on Reimbursement, Claims Submission, Denial Mgmt., Contract Mgmt., Educating Staff & Providers ICD-10 Implementation / Preparation & Planning 4

5 Medical Receptionist Front Desk Educate Staff & Providers Documentation Contract Management Revenue Coding Analysis of Denials & Coding Claims Submission Denial Management It is the collective team that makes the practice! 5

6 Revenue Cycle Reimbursement for medical practices has been impacted by various trends and healthcare industry changes over the last five to ten years. Medicare and Medicaid have started reducing physician reimbursement. Third-party payers are negotiating fee-for-service contracts with physicians resulting in reimbursement at less than 100% of charges. The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) have tightened claims data submission requirements. The government s emphasis on healthcare fraud and abuse, and compliance have heightened the importance of accurate billing. Because of such issues, medical practices are striving to improve their revenue cycle processes. ( ) 6

7 Front Desk: First Impressions They say you can t judge a book by its cover but how many of us have judged someone for how they talk or for the way they answered the phone? Opinions are often formed of people the very first time we see or hear them. Ask yourself when answering the phone, do you send a message that would form a positive opinion of yourself or even the practice. Does that message work to draw patients into the practice or do you turn them away. People s perception of us does matter. So you can see how critical it is to form that positive first impression for the success of your practice. 7

8 Medical Receptionist The medical receptionist and front desk personnel are essentially the face of any health care facility First point of contact Shape the patients first impression When you are successful in shaping the patients image into a positive one, you are shaping a long-term relationship between the provider & the patient Medical Receptionist responsibilities are NOT for everyone. To be the best medical receptionist you will not only need to fit in well to the culture of the health care organization, you will also need to have the skills and experience necessary to get the job done efficiently. 8

9 Medical Receptionist & Front Desk Personnel Sending a positive message represents a stellar image that you want to attract & retain patients who will feel positive about the practice which will drive thriving referrals through word-of-mouth. 9

10 Front Desk: Registration & Financial Counseling At each visit - Maintain and Verify Patient Information Check Insurance Eligibility and Track Authorizations Remind Patients of Outstanding Balances Encourage Prompt Payment from Patients New Patients Offer new patients the option to complete their paperwork before coming in for their scheduled appointment Established Patients This will help expedite the registration process At each visit, update patient demographics and insurance information There are 3 key performance areas to monitor for Reception & Registration: Data Accuracy, Collections & Productivity 10

11 DOCUMENTATION 11

12 Documentation Number 1 Rule of Coding? If it wasn t documented....then it didn t happen!!!! 12

13 95 or 97 Documentation Guidelines In the 1995 guidelines, the level of exam depends on the number of body areas or organ systems examined and documented. Does not specify what constitutes an exam of any area or organ system Does not indicate how much documentation is necessary to substantiate that the area or system in question has, in fact, been examined guidelines define complete exams for 11 organ systems and significantly expand the definition for multisystem exams. Either version may be used, but it is not permissible to combine them on any one patient. For example, you cannot use the 1997 guidelines for history and the 1995 guidelines for exam and medical decision making. It is permissible, however, to use the 1995 guidelines on one patient and the 1997 guidelines on another. 13

14 1995 vs History CC HPI ROS PFSH (3 of 3 required) Physical Exam Body areas & Organ Systems MDM Number of diag. & treatment options, amount of data reviewed, risk or morbidity and/or mortality (2 of 3 required) 1997 History CC, HPI or status of 3 chronic or inactive conditions, ROS, PFSH (3 of 3 required) Physical Exam Body areas & organ systems as well as elements / bullets under each body area / organ system MDM Same as

15 Documentation Guidelines for E&M Coding History 3 Key Components that Examination Determine the Level of Medical Decision Making Service Counseling Coordination of Care Nature of Presenting Problem Time Contributory Components If primary component time must be 50% of E&M Documentation Guidelines for Evaluation & Management Services are for physician services only Information obtained from:

16 The Making of an E&M Code E&M Code Chief Complaint History Examination Medical Decision Making Problem Focused Problem Focused Straightforward Expanded PF Expanded PF Low Detailed Detailed Moderate Comprehensive Comprehensive High History of Present Illness Body Areas Diagnoses or Mgmt. Options Review of Systems Organ Systems Complexity of Data Past, Family, Social History Risk to patient 16

17 Key Component #1 History The History is the subjective information the patient tells the physician based on the four elements of a history chief complaint (CC); History of present illness (HPI); Review of Systems (ROS); and Past, Family, and/or Social History (PFSH). The history contains the information the physician needs to appropriately assess the patient s condition. Not all histories have all elements. Ancillary staff (nurses, physician assistants, and so forth) are allowed to document some of the history, such as chief complaint (CC) and Past, Family, and Social Histories (PFSH), but the physician must authenticate the entries. Also, a physician can have the patient complete a form composed of questions concerning the ROS; however, the physician must evaluate the form and indicate in the medical record that the form has been reviewed (authenticated). 17 Information obtained from Buck, C American Academy of Professional Coders Medical Coding Training: CPC

18 Element #1 - CC (Chief Complaint) Is a concise statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the patient encounter that day Usually stated in the patient s own words. You do not have to use the patients own words verbatim unless the descriptive terms support the documentation Example my eyes are so dry the feel like potato chips are in them My stomach is killing me! 18

19 Chief Complaint - CC Drives the exam Example-- if the patient complains about a bump on his/her upper eyelid, the elements of the exam would be limited to that area, so long as the visual acuity is with-in normal limits The Nurse or MA can document the CC If the CC is limited, the physician may need to augment it in the HPI in order to get a Medically Necessary CC The CC establishes the Medical Necessity of the encounter The CC may be embedded in the HPI The CC must be present to establish the Medical Necessity DG: The patient s medical record should clearly reflect the CC For example, a patient that complains of an upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC. 19

20 CC (Chief Complaint) The chief complaint should tell us why the patient has come in for service on this date. A chief complaint will never be Patient is here for MRI results Patient is here for lab results Follow-up Routine visit The fact that the patient is here for results is secondary to the underlying reason the tests were performed. So the true chief complaint would be the diabetes you performed the labs for or the back pain that you ordered the MRI for. Many patients do come into the office for follow-up care, but follow-up care is not a diagnosis. The issue is requiring the follow-up care is the true chief complaint for the given date of service. 20

21 Key Component #1 Element #2 - HPI A chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present. The HPI may include the following elements: Location Site on body symptom(s) occur: Right, Left, Upper, Lower Quality Characteristics, color, dull/sharp, burning pain Severity Level of pain 1 10, widespread of rash, worse or better Duration Length of time the symptoms have existed Timing Frequency, throughout the day: morning, evening, after meals Context Cause of illness or injury Modifying Factors What circumstances makes it better or worse, e.g., Heat, Medication, etc. Associated Signs & Symptoms Pain, fever, chills 21

22 History of Present Illness -- HPI Obtain information regarding all relevant elements Just saying patient feeling better is not an adequate documentation for the HPI for that day. Separate documentation from the ROS. Need a chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present. Should contain as many of the elements that support documentation: Location Site on body symptom(s) occur: Right, Left, Upper, Lower. (Is the pain diffuse or localized? Lm-lateral or bilateral? Fixed or migratory? Radiating or referred?) Quality Characteristics, color, dull/sharp, burning pain (Is the pain sharp, dull, throbbing, stabbing, constant or intermittent, acute or chronic, stable, improving or worsening?) Severity Level of pain 1 10, with 1 being no pain and 10 being the worse pain experienced. Widespread of rash, worse or better Duration Length of time the symptoms have existed or been persistent Timing Frequency, throughout the day: morning, evening, after meals (Is it nocturnal, diurnal or continuous? Is there a repetitive pattern?) Context Cause of illness or injury (Where is pt & what is pt doing when symptoms or signs begin? What factors were present before & after?) Modifying Factors What circumstances make it better or worse, e.g., Heat, Medication, etc. (What does the pt do for relief? What meds have been taken? What were results?) Associated Signs & Symptoms Pain, fever, chills, weakness (Additional sensations or feelings) Historical data cannot be considered toward the level of service that is being reported for that day. 22

23 History of Present Illness - HPI With 1997 guidelines you can qualify for an Extended HPI with the status of 3 chronic conditions. It is more than just listing those chronic conditions, i.e., here to follow up on diabetes, hypertension, and hyperlipidemia does not do it. The provider must document the chronic conditions, i.e., hypertension-on atenolol, taking medication without complications, diabetes-patient exercising and eating 1500 calorie ADA diet, hyperlipidemia taking statin, no muscle cramps. The status of these 3 chronic conditions is the basis for an extended HPI in the 1997 guidelines. DG: If the physician is unable to obtain a history from the patient or other source, the record should clearly describe the patient s condition and/or other circumstances which may preclude obtaining a history 23

24 CC & HPI Chief Complaint: Having difficulty breathing, swelling in ankles, Cough HPI Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Patient states 5 days ago (Duration) started coughing and having shortness of breath (SOB). His chest (Location) has felt tight and uncomfortable (Quality). He rates his pain an 8 out of 10 (Severity). Has taken OTC cough and cold medication (Modifying Factors). Last night (Timing) he noticed his ankles were swelling (Associated Signs & Symptoms) Extended HPI > 4 or status of 3 chronic or inactive conditions Brief and Extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s) A brief HPI consists of 1-3 elements of the PHI DG: The medical record should describe 1-3 elements of the present illness (HPI) An extended HPI consists of 4 or > elements of the HPI DG: The medical record should describe 4 or > elements of the present illness (HPI) or associated comorbidities 24

25 Example Extended HPI Chief Complaint: Having difficulty breathing, swelling in ankles, Cough HPI Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Patient states 5 days ago (Duration) started coughing and having shortness of breath (SOB). His chest (Location) has felt tight and uncomfortable (Quality). He rates his pain an 8 out of 10 (Severity). Has taken OTC cough and cold medication (Modifying Factors). Last night (Timing) he noticed his ankles were swelling (Associated Signs & Symptoms) Extended HPI > 4 or status of 3 chronic or inactive conditions 25

26 Example Brief HPI Chief Complaint: Patient complains of an earache Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Patient states for the last 24 hours (Duration) she has had a dull (Quality) ache in her right ear (Location). Brief HPI includes documentation of one to three HPI elements 26

27 Key Component #1 Element #3 - ROS Is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. The ROS contains the following elements: Constitutional symptoms - fever, weight loss, etc. Ophthalmologic - eyes Otolaryngologic - ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary - skin and/or breast Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 27

28 Element #3 - ROS (Review of Systems) There are three types of ROS: Problem Pertinent, Extended, and Complete Documentation Guidelines: Problem Pertinent The patient s positive responses & pertinent negatives for the system related to the presenting problem should be documented. Extended The patient s positive responses and pertinent negatives for 2 to 9 systems should be documented. Comprehensive At least 10 organ systems must be reviewed for a comprehensive. Those systems with positive or pertinent negative responses must be individually documented. (For the remaining systems, a notation indicating all other systems are negative is permissible). In the absence of such notation, at least 10 systems must be individually documented. DG: The ROS may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 28

29 Example Problem Pertinent ROS Constitutional Eyes-Ophthalmologic ENMT-Otolaryngologic Cardiovascular Respiratory GI-Gastrointestinal GU-Genitourinary Musculoskeletal Integumentary Neurologic Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Patient complains of fatigue and weight gain (Constitutional), Shortness of Breath on Exertion SOBE (Respiratory), Nocturia (GU), Edema (Cardio) and Indigestion (GI). Patient denies any problems with Neuro, Psych, Endo, Eyes and ENMT. Extended ROS > 10 systems or some systems with statement others listed as negative *** Cannot state all other symptoms remain negative must list systems!!!!!! 29

30 Example Extended ROS Review of Systems Constitutional Eyes-Ophthalmologic ENMT-Otolaryngologic Cardiovascular Respiratory GI-Gastrointestinal GU-Genitourinary Musculoskeletal Integumentary Neurologic Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Patient complains of fatigue and weight gain (Constitutional), Shortness of Breath on Exertion SOBE (Respiratory), Nocturia (GU), Edema (Cardio) and Indigestion (GI). Patient denies any problems with Neuro, Psych, Endo, Eyes and ENMT. Extended ROS > 10 systems or some systems with statement others listed as negative *** Cannot state all other symptoms remain negative must list systems!!!!!! 30

31 Key Component #1 Element #4 - PFSH Past Patient s personal medical history which includes: Past major illnesses and injuries Prior operations Prior hospitalizations Current medications Allergies (e.g., drug, food) Age-appropriate Immunizations status Age-appropriate feeding/dietary status Family Patient s Family Medical History which includes medical events or diseases that may be hereditary or place the patient at risk. Includes: The health status or cause of death of parents, siblings, and children Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review Diseases of family members that may be hereditary or place the patient risk Social Patient s social factors that are age appropriate, such as: Marital status and/or living arrangements Current employment Occupational History Use of drugs, alcohol, and tobacco Level of education Sexual history (activity) Other relevant social factors 31

32 Element #4 - PFSH (Past Family and/or Social History) DG: The PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information was recorded by someone else. 32

33 Example PFSH Chief Complaint: Having difficulty breathing(sob), swelling in ankles(edema), Cough Patient has a personal history of hypertension (HTN) & Chronic obstructive pulmonary disease (COPD). Current Medications: Lisinopril, Norvasc (Amlodipine), and Albuterol. NKDA. Quit Smoking 20 years ago. Family history of Heart Disease. PFSH Established Past Medical History Family History Social History New **** 3 of 3 for New Patient / 2 of 3 for Established Patient **** Ext Ext None None 1 2 None None 1 3 Ext = Extended 33

34 Four Levels of History According to 1995 Documentation Guidelines History Elements Problem Focused Expanded Problem Focused Detailed Comprehensive CC(Chief Complaint) Required Required Required Required HPI (History of Present Illness) ROS (Review of System) PFSH (Past, Family and/or Social History) Brief 1-3 Brief 1-3 Extended 4+ Extended 4+ None Problem-pertinent 1 Extended 2-9 Complete 10+ None None Pertinent 1 Complete 2-3 Must meet or exceed all 3 elements to qualify for a level 34

35 History Level Key Component #1 Chief Complaint: Having difficulty breathing (SOB), swelling in ankles(edema), Cough HPI Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Brief 1-3 Brief 1-3 Extended > 4 Extended > 4 ROS Constitutional Eyes-Ophthalmologic ENMT- Otolaryngologic Cardiovascular Respiratory GI-Gastrointestinal GU-Genitourinary Musculoskeletal Integumentary Neurologic Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic None > 10 PFSH Past Medical History Family History Social History Established New/Initial None None 1 2 None None 1 3 Level of History PF EPF Detailed COMP 35

36 Key Component #2 Examination Systems examined should differ based on the nature of the presenting problem, i.e., Stubbed toe vs. SOB DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems 36

37 Key Component #3 Medical Decision Making (MDM) When working with MDM (medical decision making) while leveling E&M codes, it is important to understand what is involved in a straightforward, low, moderate or high complexity medical decision. Which of the following is not considered when determining medical decision making for an E&M code? A. The amount and/or complexity of data regarding the patient B. The risk involved, including the possibility of complications and/or death C. Number of diagnoses and/or signs and symptoms D. The time it takes the provider to treat the patient 37

38 MDM & S.O.A.P Note Subjective This is the patient s description of their current condition in narrative form Objective Findings of the physical exam and test results by the physician Assessment A summary of the patients symptoms or diagnosis Plan A description of what the provider will do to treat the patients concerns or condition Most providers use the S.O.A.P format of notes. MDM is actually the A&P portion of their S.O.A.P note 38

39 MDM Is comprised of: How many problems or management options How much data How much risk is associated with that patients visit Often you find a list of diagnoses that is intended to convey the complexity of the visit, i.e., if a patient has 6 or 8 diagnoses they must be highly complex. What an auditor or a reviewer is looking for is how many of those diagnoses did the provider actually deal with or if they didn t actively deal with that particular diagnosis how did that comorbid condition contribute to the problem that the provider was actually dealing with or managing that day. 39

40 MDM If the chronic diagnoses the patient has or the medication that a patient is taking for their chronic condition(s) is being considered in dealing with the reason the patient is in the office that day, then document those elements so that they can be considered towards the cognitive labor of that visit. Data elements require a description of why the test(s) are being ordered to support medical decision making. Document what test(s) were ordered and why they are being ordered, what is being evaluated or examined as a result of that data. The risk is based on the physicians determination of the patient s probability of becoming ill or diseased, having complications or dying between this encounter and the next. 40

41 MDM It is really important for providers to state it if the patients has a chronic condition(s) that are severely worsening or an acute conditions with systemic symptoms that might result in a loss of life, limb or organ system. This helps the reviewer understand the complexity of the visit. Just simply listing diagnoses does not mean that the visit was complex DG: Labs that are acted upon contribute to the medical decision making complexity DG: Tests ordered count toward data points of MDM. 41

42 Additional Component: Medical Necessity Even though only two of the three components are required, Medical Necessity is the overarching criterion for payment in addition to individual requirements of a CPT code Medical Necessity is best described in the MDM component of the medical record Time spent must be documented as the element discussed when more than 50% of the total time in the encounter was performed on counseling and coordination of care by the provider Just listing time spent does not do it--there has to be documentation to support it. 42

43 Documentation supports Medical Necessity A few words make a huge difference words like worsening, not responding as expected, major complications, severe, extreme, and profound lend credence to the higher levels of service. It s not the volume of documentation but the type of documentation that goes into the encounter. 43

44 Documentation: Evaluation & Management Using 1995 Documentation Guidelines for E&M Services: An established patient is being seen in a doctor s office. The provider performs a Detailed History (Extended HPI, Extended ROS, and Pertinent PFSH) + Detailed Exam ( 95 Guidelines extended exam of 2-7 body areas) + Moderate MDM as stated in the scenario. An established office visit requires two out of three key components, which is for this encounter. 44

45 Documentation: EMR & Audit Issues The number one risk with EMRs is cloning of patient information. Cloning is also referred to as copy & paste, cut & paste or carrying forward. This causes the medical record to become similar or worded exactly as previous entries or encounters cut & paste has a high malpractice risk in a court of law Cloning affects physician documentation & is the # 1 area that has the most risk of fraud/abuse Cloning of past complaints or symptoms in current documentation can lead to a multitude of errors, including treatment and could represent more than what was actually done 45

46 Documentation Scenario A patient is seen for flu like symptoms and was exposed to several children where she works that have been complaining of a sore throats. The patient states she has taken Tylenol and Sudafed for sever congestion & fever. She is taking medications for HTN. She states she is taking her medications as and is walking 3x s/week until recent symptoms of increased BP. Documented: Allergies, Current Meds & PFSH Pertinent ROS Detailed Examination Moderate Complexity MDM with prescription drug management for 1 chronic problem which is currently worsening & 1 new acute diagnosis with systemic symptoms where treatment is complicated by comorbid condition of HTN. Provider reported (level 3) Due to documentation of key components, this should have been coded as a (level 4) 46

47 Documentation Must reflect the intent of the CPT code and the wording of the Diagnosis 47

48 Coding 48

49 Coding: New vs Established Decision Tree -for New-vs- Established Patients Received any professional service from the physician or another physician in group of same specialty within last three years? Yes No Exact same specialty? New patient Yes No Exact same subspecialty? New Patient Yes No Established New patient A new patient is one who has not received any services by the same physician, or a physician within the same group with the same specialty for 3 years. Not reporting is a missed opportunity Information provided from AMA CPT 2012 Professional Edition 49

50 New Patient For E/M code 99201: History level is problem focused Examination is problem focused MDM is straight forward Example Initial office visit with a 9-month old female with diaper rash Initial office visit for a 22 year old male with a small area of sunburn requiring first aid. Information provided from AMA CPT 2012 Professional Edition 50

51 New Patient For E/M code 99202: History level is expanded problem focused Examination is expanded problem focused MDM is straight forward Example Initial office visit for a 13 year old male patient with comedopapular acne of the face, unresponsive to over-thecounter medications Information provided from AMA CPT 2012 Professional Edition 51

52 New Patient For E/M code 99203: History level is detailed Examination is detailed MDM is of low complexity Example A 50 year old new patient presents for an initial office visit to discuss a surgical vasectomy for sterilization. The history & examination are detailed & the MDM is of low complexity Information provided from AMA CPT 2012 Professional Edition 52

53 New Patient For E/M code 99204: History level is comprehensive Examination is comprehensive MDM is of moderate complexity Example Initial office visit for a 7 year old female child with diabetes mellitus, new to area, past history of hospitalization times three. Information provided from AMA CPT 2012 Professional Edition 53

54 New Patient For E/M code 99205: History level is comprehensive Examination is comprehensive MDM is of high complexity Example: A 30 year old male who is a new patient has an initial office visit for severe depression that has led to frequent thoughts of suicide in the past several weeks and is acute today. More than an hour is spent discussing the patient s problems and options. His past medical history is negative. His social history reveals that the patient suffers from sleeplessness; smokes between 2 3 packs of cigarettes a day; he drinks 12 to 14 cups of coffee a day; and he denies current use of drugs. Further documentation indicates a comprehensive exam was conducted with a high MDM complexity. Information provided from AMA CPT 2012 Professional Edition 54

55 Est. Patient: Office visit for the evaluation & management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Provider must be in the office or immediately available Employee must have credentials to perform the service Service must be part of a documented treatment plan 55 Information provided from AMA CPT 2012 Professional Edition

56 Est. Patient: For E/M code 99212: History level is problem focused Examination is problem focused MDM is straight forward Example An established 46 year old patient presents with an irritated skin tag. A problem focused history and examination are done. MDM is of low complexity. 56 Information provided from AMA CPT 2012 Professional Edition

57 Est. Patient: For E/M code 99213: Example History level is expanded problem focused Examination is expanded problem focused MDM is of low complexity A established 36 year old woman presents with diarrhea for the past 6 days. Her temperature is 102 degrees Fahrenheit. An expanded problem focused history and examination are done. MDM is of low complexity. Information provided from AMA CPT 2012 Professional Edition 57

58 Est. Patient: For E/M code 99214: History level is detailed Examination is detailed MDM is of moderate complexity Example Office visit for a 32 year old female, established patient, with new onset right lower quadrant pain. Information provided from AMA CPT 2012 Professional Edition 58

59 Est. Patient: For E/M code 99215: History level is comprehensive Examination is comprehensive MDM is of high complexity Example An established 50 year old female patient complains of frequent fainting. The history and examination are comprehensive, and the MDM is of high complexity. 59 Information provided from AMA CPT 2012 Professional Edition

60 Coding Accurately coding data is essential for proper reimbursement. Accurately coded diagnoses and procedures are also important for financial rate setting and future reimbursements. Payment rates are based on historical coded data. Payers will deny claims if the ICD-9-CM is not properly linked to the appropriate CPT code to show the reason the procedure was performed Inaccurate CPT coding can cause many issues Decreased payment for services or procedures Denied or pending payment for services or procedures Implication of fraud and abuse 60

61 ICD-9-CM Diagnosis codes are to be used at their highest number of digits available. ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. 3 digits are the heading of a category code 3 digits may be further subdivided by the use of the 4 th and/or 5 th digit. This provides greater detail. 3 digits codes can be used only if it cannot be further subdivided. When 4 th and/or 5 th digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code. 61

62 ICD-9-CM The first diagnosis code that is listed for the patients visit should be the reason the patient sought medical care. Any other conditions that are discovered are listed subsequently to substantiate adjunct services such as laboratory. ICD Codes are to be listed in order of the provider's perceived acuity abscess upper arm & forearm acne unspecified viral warts, unspecified psoriasis other 62

63 ICD-9-CM If two or more diagnoses equally meet the definition for principal diagnosis, either diagnosis can be sequenced as the first-listed diagnosis. Codes for symptoms, signs, and ill-defined conditions from Chapter 16 of the ICD-9-CM manual are not to be used as a principal diagnosis when a related definitive diagnosis has been established. However, codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. 63

64 ICD-9-CM Example: A patient is seen in the office complaining of skin lesions on her foot that appeared two days ago. The lesions appear to have pus and necrosis of the surrounding tissue. The physician diagnosed the patient with a chronic skin ulcer. The initial diagnosis for the skin ulceration will be the first diagnosis code that is entered in the patients EMR. If the physician determines that the ulcer is due to diabetes and poor circulatory problems then these multiple conditions will be listed after the initial condition that caused her to seek medical attention. These additional diagnosis codes are not the reasons why the patient sought medical care but are contributing factors. 64

65 ICD-9-CM Use Additional Codes to provide a more complete picture of the diagnosis or procedure. It is mandatory that you use additional codes if the documentation supporting it is found in the patients record. Code First Underlying Disease Example Cataract associated with other disorders Diabetic cataract Code first diabetes (249.5, 250.5) 65

66 ICD-9-CM You will reference the alphabetic index first in Volume 2 of the ICD-9-CM manual and then locate the diagnosis code identified in the Index of the Tabular list in Volume 1 For certain conditions it is important to record both the etiology (cause) and the manifestation (symptom) of the disease. Example gonococcal cystitis Etiology (disease) Manifestation 66

67 Diagnosis Coding Why should you care? It s all about the value. Ask yourself--what is the value of the service you provide? Accurate diagnosis coding supports the level of work performed by the clinician It identifies the reason for the encounter It proves the Medical Necessity for the service It proves the acuity of the patient It proves a Payable Service Compliance 67

68 Role of the Clinician Identify the reason(s) for the patients services in ICD-9-CM Diagnosis Codes Document to prove the above Diagnosis coding paints a picture of the patient. 68

69 What would your patient look like? 69

70 Paint a picture of this scenario Mr. Harper, a 66 year old established patient comes in to the clinic today and is diagnosed with the flu and a fever. He thinks he might have pneumonia. He takes insulin to manage his type II diabetes and he had a heart attack 1 year ago. Today, the physician determined that Mr. Harper has the flu with an URI. Mr. Harper was also prescribed antibiotics. 70

71 Would you paint a partial picture? Most common coding scenario would be Influenza w/ other respiratory manifestations This is correct, but the coding is not specific enough nor is it complete. 71

72 More specific & complete picture Influenza w/ other respiratory manifestations Type II Diabetes w/ complications Benign Hypertensive heart disease w/ heart failure 428.x Heart failure V58.67 Long-term use of Insulin Document the composite picture of the patient's health status, by assigning ICD-9-CM codes that include co-morbidities. 72

73 A Coding Misconception It does not matter what diagnosis I code; I get paid the same Wrong!!! 73

74 Reality Is Diagnosis Coding Traditional Clinician Reimbursement Fee-for-Service (CPT-based) Based on RBRVS units & fee schedule All-inclusive rate for services rendered RHCs & FQHCs Current/Future Reimbursement (ICD-9 impact) Payer coverage policies based on specific diagnosis(es) Medicare PQRI incentive model Quality measures based on diagnosis Medicare Advantage Enhance reimbursement for patients of HCC (hierarchical condition category based on ICD-9-CM coding) Value-based reimbursement (VBR) 74

75 Rules of Diagnosis Reporting Code all conditions that affect/require care Code reasons for all studies Code the main reason for the encounter (determined by the physician) as the 1 st listed diagnosis Patient with prostate cancer evaluated for bronchitis bronchitis is the first=listed diagnosis for today Code specificity rather than generality Acute vs. chronic Controlled vs. uncontrolled Do not report unconfirmed diagnoses on the encounter form 75

76 Coding: Signs & Symptoms A patient was seen at for symptoms of a sore throat, fever, and headache. The physician decides to have the nurse perform a throat culture during the visit. The rapid culture is negative but is sent overnight to the lab to rule out strep throat. How would you code the patient s encounter using the ICD-9-CM manual? A. Suspected Strep Throat B. Strep Throat C. Sore throat, fever, and headache D. All of the above 76

77 Coding: Labs Properly link the reason the lab was ordered/performed Payers will deny claims if the ICD-9-CM is not properly linked to show the reason the lab was ordered/performed. Diagnosis codes must be applicable to the patient s symptoms and/or conditions and must be consistent with the documentation in the patient s medical record. Many lab tests have Frequency Limitations so you must have a valid ABN (Advanced Beneficiary Notice) on file when ordering one of these tests for Medicare Patients. 77

78 Lab Medicare National Coverage Determination Frequency Test Fecal Occult Blood Glucose Testing (Blood) Hemoglobin A1C (Glycated Hemoglobin / Glycated Protein) HIV Testing (Diagnosis) Lipid Testing (Lipid Panel, Cholesterol, LDL, HDL, Triglycerides) PSA (Prostate Specific Antigen) Thyroid testing (TSH, T3, T3 Uptake, T4, FT4) V70.0 (is a non-covered ICD-9-CM code for all NCD edits), i.e., UHC recommends choosing an ICD-9-CM that supports medical necessity & should have a diagnosis code of attached instead of V

79 Lab Test: Medicare Non-Covered ICD-9-CM Codes for All NCD Edits V15.85 V V16.2 V16.40 V V16.52 V16.59 V V16.9 V V17.3 V17.41 V17.49 V V17.89 V18.0 V18.11 V18.19 V18.51 V18.59 V18.61 V18.69 V V18.9 V V19.8 V V20.2 V V20.32 V V28.9 V V50.9 V53.2 V V60.9 V V62.1 V65.0 V65.11 V65.19 V68.01 V68.09 V V70.9 V V73.99 V V74.9 V V75.9 V76.0 V76.3 V V76.43 V V76.47 V V76.50 V76.52 V76.81 V76.89 V76.9 V77.0 V V77.99 V V78.9 V V79.9 V V80.3 V V81.6 V V82.6 V82.71 V82.79 V82.81 V82.89 V

80 Lab: Medicare PSA Test Offerings Medicare will reimburse a routine PSA screening once per year Screening for PSA benefit, use ICD-9- code V76.44 Screening vs Diagnostic purposes has different coverage criteria Always have the patient sign an ABN due to Medicare's frequency limitations 80

81 Lab: ICD-9-CM ICD-9 codes acceptable for diagnostic PSA testing V

82 Lab: Documentation Guidelines DG: Make sure that any/all lab results that are scanned to the patients EMR are signed and dated by the physician Without the scanned signed and dated note, the order cannot be considered as valid for reimbursement, or towards the level of service 82

83 Coding: HCPCS Coders may find that the same procedure is coded at two or even three levels. Which code is correct? There are certain rules to follow if this should occur. When both a CPT & a HCPCS Level II code have virtually identical narratives for a procedure are not identical (e.g., the CPT code narrative is generic, whereas the HCPCS Level II code is specific), the Level II code should be used. Be sure to check for a national code when a CPT code description contains an instruction to include additional information, such as describing a specific medication. For example, when billing MDCR/MDCD for supplies, avoid using CPT code for supplies & materials (except for spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). There are many HCPCS Level II codes that specify supplies in more detail. Information provided by 2012 HCPCS Medicare Level II Expert 83

84 HCPCS: MDCR Section of the Affordable Care Act adds several new preventive services to the list of Medicare-covered FQHC services. Additionally, the new law calls for the creation of a new Medicare reimbursement structure for health centers beginning in In order to create this system, the law requires health centers to begin reporting Healthcare Common Procedure Coding System (HCPCS) codes beginning January 1, These codes are used to indicate the types of services being provided at each visit. CMS has updated their Claims Processing Manual for FQHCs. 84

85 HCPCS: MDCR MLN Matters Number: MM7038 Effective January 1, 2011, The Affordable Care Act revised a list of professional component preventive services an FQHC can bill for. IPPE Initial Preventive Physical Examination (G0402) Other screening & preventive services Vaccinations & administration of PNU, FLU, & HepB Screening Mammogram &Pelvic Exam (G0101), Pap Smear (Q0091), Screening tests for Prostate Cancer and Colorectal Cancer Training services for Diabetes Self Management (DSMT) Bone Mass Measurement Glaucoma Screening Services for Medical Nutrition Therapy Screening blood test for Cardiovascular Screening test for Diabetes Additional preventive services, i.e. Smoking & Tobacco Cessation counseling visit (G0436 & G0437) 85

86 Coding: Health Check Health Check providers must determine whether members requesting a periodic prevention health screening have already received that periodic screening. An exception to the rule would be a Periodic screening for a foster child in state custody. A Health Check visit and a Dental Visit are required within 10 days of a child s transition to state custody 86

87 Health Checks Remember CMOs will reimburse you for performing Health Checks. When a client calls to schedule a sports physicals remember you could be performing a Health Check if that client has not had a screening performed within the guidelines. Medicaid will reimburse FQHCs for Health Check screenings no matter who his/her PCP is if they are eligible for the screening. 87

88 ICD-9-CM: E-Codes E-codes: Are never reported as the principal diagnosis. Rather, E-codes are used to clarify the cause of an injury or adverse effect. E-code term describes the external circumstances under which an accident, injury, or act or violence occurred. You must read all the information under the term in the E-code index of Volume 2 before locating the E-code in the section of Volume 1, Tabular list. 88

89 E-Codes E-codes are assigned during the initial encounter, not during subsequent treatment, with the exception of acute fracture coding. E-Codes are not accepted by some insurance carriers. Check with you local carriers before submitting E-Codes with your claims. For instance Medicaid does not accept E-Codes rendered in an FQHC. 89

90 E-Codes Example: E860-E869: Accidental poisoning by other solid & liquid substances, gases, and vapors Example: A 20 year old female is brought into the office with memory disturbance after an accidental exposure to lead paint. Code: Lead paint Memory Disturbance E861.5 Accidental poisoning by lead paint 90

91 E-Codes E930-E949: Drugs, Medicinal & Biological substances causing adverse effects in Therapeutic Use Example: A mother brings in her 4 year old female child to see the pediatrician for vaccinations. That evening the child s temperature reaches 104.6, and is rushed by the mother to the emergency department. Code: Fever E949.9 Unspecified vaccine 91

92 ICD-9-CM: V-Codes V-codes are supplementary classifications of factors influencing a person s health status and contact with health services. V-codes are used under the following circumstances Non-sick person seeks health services to receive a vaccination Person with a known disease or injury presents for specific treatment of that condition When circumstances influence a patient s health status To indicate the birth status & outcome of delivery of a newborn 92

93 V-Codes Example: V-code: A well child receives a polio vaccination: V04 Need for prophylactic vaccination & inoculation against certain diseases V04.0 Poliomyelitis 93

94 Modifiers Modifier descriptions are located in Appendix A of your CPT Manual Modifiers can: Tell a story Reduce your reimbursement Allow for reimbursement Allow for additional reimbursement Documentation must support the use of any modifier 94

95 Modifiers A modifier is a two-position alpha or numeric code that is added to the end of a CPT code to clarify the services being billed. Modifiers provide a means by which a service can be altered without changing the procedure code. They add more information, such as the anatomical site, to the code. Information provided by 2012 HCPCS Medicare Level II Expert 95

96 Modifiers Modifier 25 attached to E&M Code Check with your payer to determine if a modifier is required when labs are performed. Most payers do not require this. However if CPT code was billed, Modifier 25 would have been attached to a unit Vaccine Administration TD In addition, they help eliminate the appearance of duplicate billing and unbundling. Modifiers are used to increase accuracy in reimbursement, coding consistency, editing, and capture payment data. 96

97 Modifier 25 Is a Significant, Separately Identifiable Evaluation & Management service by the SAME provider on the same day of the procedure or other service. Be careful using this modifier. Example: A 25 year old established patient presents to her primary care physician complaining of wrist pain. During the examination she asks her physician about a growth on her left leg. After completing the Expanded Problem Focused History and Examination, her physician discusses different options regarding the growth on her leg and she decides to have it removed by shave technique. The physician recommends that she try an anti-inflammatory mediation for her wrist pain. After consent is obtained, the physician using a 10-blade shaves the lesion measuring 1.3cm from her leg and sends the specimen to the lab for pathologic analysis. The MDM id Moderate

98 Modifier 59 Is a Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support the use of any modifier. Information provided from AMA CPT 2012 Professional Edition 98

99 Modifier 59 Example (level 3, est. pt.) 1, 2, 3, & (destruction of any benign lesion; up to 14 lesions) (I&D, simple) 1 Always make certain you link your ICD-9 code to your CPT code abscess upper arm & forearm acne unspecified viral warts, unspecified psoriasis other Information obtained from AMA CPT 2012 Professional Edition & ICD-9-CM 99

100 Modifiers: EP (EPSDT-Early Periodic Screening Diagnosis & Treatment Program) Modifier used for Medicaid Health Check services provided for individuals under the age of twenty-one FP (Family Planning) Modifier used for providing services for family planning program TJ (Program group, child and/or adolescent) To indicate the member is a state custody foster care child, in addition to the appropriate Health Check codes and modifiers when performing 100

101 Combinations Codes Documentation in the medical record of conditions that are related to each other might lend themselves to combination codes Congestive Heart Failure CHF due to Hypertension codes to which does risk adjust whereas Hypertension does not. In addition to the , we would also have to code the CHF code. Similarly in Diabetes if we report code for diabetes with ophthalmic manifestations we would also have to code the particular ophthalmic manifestations of proliferative retinopathy These higher specificity code(s) paint a picture of the patient that requires more medical care. DG: Using the linkage terms of due to or associated with will allow that higher specificity code to be reported without a lot of additional documentation. 101

102 Codes Commonly Overlooked With the diagnosis of Anemia, if the provider includes Neutropenia in the description of that Anemia, it actually codes to agranulocytosis which does risk adjust. This neutropenia has consequences for the older population that make it more likely that this patient is going to have some kind of service as a result. Similarly, anemia that is due to cancer--risk adjusts. With the diagnosis of Pneumonia if the organism is known this lends to a higher specificity code or if documentation shows that the patient aspirated before developing pneumonia, a different code for the pneumonia is appropriate. 102

103 Coding the Complex Patient Scenario: Billed as a 99213, diagnosis code of Malaise The PCP seen a patient with colon cancer that had spread to the liver, the patinet has diabetic neuropathy that is causing progressive weakness in the extremities, headaches due to continued anemia and asthma with COPD. The physician acknowledged that the patient did have several problems but he wasn t sure if he could actually code for those cancer related conditions since he was not the oncologist. These related conditions are affecting the management and potentially the treatment plan for the patient as regard to the symptoms that they came in for but also might have a bearing because of the medications that the patient is on for the treatment of their cancer. So all of these things contribute to the cognitive labor of the encounter. Most of the time, a patient like this is really suffering and it is not a visit that a provider can hurry through; it s a visit that the provider really needs to take his/her time with and understand all the different things going on with that patient and sometimes the provider is at a loss because they are unable to take care of any of the necessary things the patient came in for. 103