Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas

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1 Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas

2 CPT Codes vs. ICD Codes Category 1 CPT Codes CPT Codes Describe a procedure or service identified with a five-digit numeric CPT code and descriptor nomenclature Used to report physician services: medical, surgical, radiology, laboratory, anesthesiology and E/M There are approximately 298 E/M CPT codes ( ) Category 11 CPT Codes Optional codes developed principally to support performance measurement PQRS is reported using Category 11 CPT Codes Category 111 CPT Codes Temporary codes for emerging technology, services and procedures ICD Codes Describe signs, symptoms, injuries, diseases and conditions Describes the clinical condition of the patient to support the medical necessity or the procedure or service (to describe the medical necessity of the CPT code chosen) There are 17,000 ICD-9 Diagnosis Codes

3 Commonly Used CPT Codes When Time Matters New Patient Evaluation Established Patient Evaluation Prolonged Service with Direct Patient Contact If the time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, bill the E&M code and If the time equals or exceeds the threshold time for code by no more than 29 minutes, bill and one unit of code One additional unit of is billed for each additional 30 minutes extended duration Code Typical Time for Code Threshold to bill Threshold to bill minutes 15 minutes 25 minutes 40 minutes 45 minutes 60 minutes 40 minutes 45 minutes 55 minutes 70 minutes 75 minutes 90 minutes 85 minutes 85 minutes 100 minutes 115 minutes 120 minutes 135 minutes

4 Prolonged Service With Direct Patient Contact Case Examples of Using and Visit CPT code (15 min). Total duration of face to face service was 65 minutes. Bill CPT code and one unit of (Threshold 45 Min) Visit CPT code (10 min). Face to face service was 35 minutes. Cannot bill for prolonged services because the threshold of 40 minutes was not met Visit CPT code (40 min). Face to face service was 75 min of Counseling. Bill CPT code and one unit of (Threshold 70 min) 60 minute office visit that was Counseling: Cannot code 99214, which has a typical time of 25 minutes, and one unit of For Counseling and Coordination of Care, must bill the highest level code in the CPT code family (99215 which has a 40 minutes time units associated with it). If the additional time spent beyond is 20 minutes and does not meet the threshold time for billing prolonged services (60 minutes with a threshold for of 70 minutes) can only bill a

5 CPT Evaluation and Management Coding New Patient (3 out of 3) Code History Exam Medical Decision Making Problem focused Problem focused Straightforward Extended problem focused Extended problem focused Straightforward Detailed Detailed Low complexity Comprehensive Comprehensive Moderate Complexity Comprehensive Comprehensive High Complexity

6 CPT Evaluation and Management Coding Established Patient (2 out of 3) Code History Exam Medical Decision Making Minimum services; Physician not required Problem focused Problem focused Straightforward Extended Problem Focused Extended Problem Focused Low complexity Detailed Detailed Moderate Complexity Comprehensive Comprehensive High Complexity

7 Defining Evaluation/Management Services Seven Components Recognized 1. History 2. Examination 3. Medical Decision Making 4. Nature of the Presenting Problem 5. Consultation 6. Coordination of Care 7. Time

8 Example Case History: HPI, ROS, PFSH 32 year old woman with PMH of TTH. Onset of H/A age 14. H/A associated with vomiting, photophobia & dysfunction. The initial headaches were left hemicranial. 8 year history of chronic daily headaches. The headaches are debilitating with a pounding, throbbing quality. Taking hydrocodone/acetaminophen daily (4-6/D) for 5 years; was taking butalbital before hydrocodone/acetaminophen. Disability for 2 years. New onset: visual blurring OD; hypalgesia and possible mild paresis in RUE; transient confusion

9 Key Components of the HPI HPI Elements (8) Problem Focused Expanded Problem Focused Levels Detailed Comprehensive Location Brief Brief Extended Extended Quality 1-3 elements 1-3 elements 4 or more 4 or more elements Severity Elements Duration Timing Context Modifying factors Associated signs or symptoms

10 Categorization Neurological Single System Examination 1 point General Appearance of Patient 1 point Measurement of Any 3 or 7 Vital Signs 1 point Ophthalmologic Examination Cardiovascular Examination 1 point Examination of Carotid Arteries 1 point Examination of Heart 1point Examination of Peripheral Vascular System 5 points possible Higher Cortical Functions 8 points possible Cranial Nerves 1 point Sensation 1 point Muscular Strength 1 point Muscle Tone 1 point Deep Tendon Reflexes 1 point Coordination 1 point Gait and Station Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997

11 Components of Neurological Examination Level of Exam Problem focused Expanded Problem Focused Detailed Comprehensive 1997 Single Organ System 1-5 elements At least 6 elements At least 12 elements Perform all components Document all elements in Constitutional Eyes Musculoskeletal Neurological Document 1 element in Cardiovascular

12 Billing and Coding in Neurology and Headache Level of Care Physical Exam 99201?; 99202?; 99203?; 99204?; 99205? Exam: 25 Bullets BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Carotids and PE WNL Neurological Exam Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes Sensation; All WNL

13 Medical Decision Making CPT coding provides only descriptive assessments, not numerical values CPT gives no precise quantative standards of measure, for the MDM elements but MDM asks us to define a quantative assessment using qualitative descriptors However, there are no quantitative values to define the elements of MDM The MDM Elements Are The number of diagnosis or management options The amount of data reviewed or ordered The complexity of data reviewed The complexity of data ordered The risk of the presenting problem The risk of diagnostic procedures o The risk of management options selected

14 Medical Decision Making Scoring System Methodology to determine level of MDM have been developed. There are several systems currently in use. The scoring guides are based on a point system that takes qualitative information collected by the provider and translates it into quantitative data. More points translate into a higher level of service. Examples of the scoring systems that follow can be found in the CMS Evaluation And Management Coding and Documentation Reference Guide and other reliable sources In general scoring systems are not part of the 1995 or 1997 Evaluation and Management Documentation Guidelines

15 Medical Decision Making 1. Number of Diagnosis and Management Options Quotes from the 1997 Documentation Guidelines (CMS) For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated, or implied in documented decisions regarding management plans and/or further evaluation. For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or inadequately controlled, worsening, or failing to change as expected. For a presenting problem without an established diagnosis, the assessment may be stated in the form of differential diagnosis or as a possible, probable, or rule out (R/O) diagnosis Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997

16 Case Example MDM Does Not Ask For The Final ICD Diagnoses Level of Care 99201?; 99202?; 99203?; 99204?; 99205? Physical Exam Exam: 25 Bullets BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Carotids and PE WNL Neurological Exam Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes Sensation; All WNL Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct) 2. Number of Diagnosis and Treatment options >4

17 Medical Decision Making 2. Amount and/or Complexity of Data to be Reviewed Data to be reviewed includes: Ordering tests: Reviewing tests and discussion with physicians interpreting tests; direct review and interpretation of actual images, tracings specimens. Old Records: It also includes obtaining old records for review and documentation of actual findings in the old records. Document any tests ordered or data reviewed The type of diagnostic testing ordered, planned, scheduled or reviewed Review old medical records, lab, radiology and diagnostic tests Discussion of the case or tests with another physician Direct visualization of imaging or other tests

18 Case Example Level of Care 99201?; 99202?; 99203?; 99204?; 99205? Physical Exam Exam: 25 Bullets BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Carotids and PE WNL Neurological Exam Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes Sensation; All WNL Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct) 2. Number of Diagnoses and Treatment Options >4 Complexity of Data Reviewed Reviewed >4 22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004); EEG (2005); MRI Head (2005) Ordered >4 MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care?

19 Medical Decision Making 3. RISK What is meant by Risk? Risk of significant complications, morbidity, and/or mortality Issues to consider and Documentation Recommendations Risk associated with the presenting problem Risks associated with the diagnostic procedure(s) Risks associated with the possible management problems

20 Medical Decision Making 3. Risk of Complications and/or Morbidity or Mortality The Table of Risk is published in the 1997 Documentation Guidelines Risk of the Presenting Problem(s) Risk of Diagnostic Procedure(s) Ordered Risk of Management Options The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk. Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997.

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22 Case Example Level of Care Physical Exam Exam: 25 Bullets BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Carotids and PE WNL Neurological Exam Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes Sensation; All WNL Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct) Complexity of Data Reviewed Risk Reviewed 22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004) Ordered MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care? NPP: a disease, condition, illness, injury, symptom sign, finding, complaint or other reason for the encounter, with or without a diagnosis being established at the time of the encounter Using Table of Risk: One of more chronic illnesses with chronic exacerbation, progression or side effects of treatment Abrupt change in neurologic status; seizure, TIA, weakness, sensory loss Drug therapy requiring extensive monitoring for toxicity

23 MDM: Qualitative Data into Quantative Data Two of the Three Components Determine the final Level Table A1 (and A2) Number of Diagnosis and Management Options Add up the points for the total May use the larger of Table A1 or A2 for total MDM Table B Data Reviewed or Ordered Add up the points for the total Table C Level of Risk The final Risk is the highest of the three Risks from the Table of Risks Table D Final level of MDM Requires that two of the three components are met or exceeded

24 CMS E&M Coding and Documentation Reference Guide Tables A1 and A2 Table for Management Options: Table 1A Examples of commonly prescribed treatments One (1) point value is the most common designation for most treatments. Table 1A, Number of Diagnoses is most commonly used Number of Diagnoses and Management Options: (Table 1B) Difficult to have specific table that is all inclusive for Management Options Continue the same therapy or no change in therapy do not count unless specific therapy is described, documented or reviewed. Drug doses for current medications are not required, however, the record must reflect conscious decision making to make no dose changes in order to count for coding purposes.

25 Medical Decision Making Scoring System Table A1:Number of Diagnoses or Treatment Options. Number of Diagnoses or Treatment Options Each new or established problem for which the diagnoses and/or treatment plan is evident with or without diagnostic confirmation Two plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in the record: requiring diagnostic evaluation or confirmation 3 plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in the record: requiring diagnostic evaluation and confirmation 4 or more plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in the record: requiring diagnostic evaluation and confirmation Points Total 4

26 Management Options: Table A2 Table A2 could never by all inclusive; following are examples Do not count as treatment option s notations such as: Continue same therapy or no change in therapy if specific therapy is not described 0 Drug management includes same therapy or no change In therapy if specific therapy is described. The record must reflect conscious decision-making for coding purposes 3 new/current meds >3 new/current meds 1 2 Physical therapy, occupational or speech therapy 1 IV fluids, such as infusion in infusion center 1 Conservative measures such as rest, diet, etc 1 Discuss case with another physician or admit to hospital 1

27 CMS E&M Coding and Documentation Reference Guide Table B: Data Reviewed or Ordered Order and/or review medically reasonable and necessary clinical laboratory procedures Order and/or review medically reasonable and necessary diagnostic imaging studies in Radiology section of CPT Order and/or review medically reasonable diagnostic procedures in Medical section of CPT 1-3 procedures 4 procedures 1-3 procedures 4 procedures 1-3 procedures 4 procedures 1 point 2 points 1 point 2 points 1 point 2 points Discuss test results with performing physician Discuss case with other physician(s) involved in patient s care or consult another physician; does not include referring patient to another physician for future care Order and review old records. Record type and source must be noted. Must be tied to patient care protocol Independent visualization & interpretation of image/ test for MDM. Each visualization & interpretation is a point Review of physiologic monitoring or testing data. No summary With summary Total points 1 point 1 point 1 point 2 points 1 point 1 point 4 points

28 CMS E&M Coding and Documentation Reference Guide Table C:Risk of Complications &/or Morbidity or Mortality 1. Minimal (level 1) 2.Low (level 1 3. Moderate (level 2) 4 high (level 3) Final Risk determined by highest of 3 components below Risk of presenting problem (Risk of morbidity, mortality, comorbidities, or complications with prolonged functional impairment) 1. min 2. low 3. mod 4. high Risk of diagnostic procedure(s) ordered or reviewed 1. min 2. low 3. mod 4. high Risk of management options selected 1. min 2. low 3. mod 4. high

29 Table D: Assignment of Medical Decision Making 2 of 3 components in table D must be met or exceeded A. Number of diagnoses or management options 1 Point Minimal 2 Points Limited 3 Points Multiple 4 Points Extensive B. Amount and complexity of data reviewed / ordered 1 Point None/ Minimal 2 Points Limited 3 Points Multiple 4 Points Extensive C. Risk Minimal Low Moderate High Type of Medical Decision Making Straight- Forward Low Complexity Moderate Complexity High Complexity

30 CPT Evaluation and Management Coding New Patient (3 out of 3) Code History Exam Medical Decision Making Problem focused Problem focused Straightforward Extended problem focused Extended problem focused Straightforward Detailed Detailed Low complexity Comprehensive Comprehensive Moderate Complexity Comprehensive Comprehensive High Complexity

31 Consultation and Coordination of Care TIME In certain circumstances TIME Is the controlling factor in determining the level of an E/M service Intraservice times are defined as face-to-face time for office and other outpatient visits The amount of time spent becomes the sole determining factor of the level of the E/M code This is true of the exam and MDM components which do not need to be performed

32 Billing and Coding in Neurology and Headache Time determines the level of E/M service when counseling and/or coordination of care dominates > 50% the encounter Counseling and coordination is separate from the history, physical exam and medical decision making Consultation and Coordination of Care is a common scenario for Established Patient visits for Neurologists and Headache specialists The extent of consultation and/or coordination of care must be documented in the medical record independent of the three key components

33 Consultation and Coordination of Care Time Counseling patient and/or family documention (2013) Diagnostic results, impressions, and/or recommended studies Prognosis Risks and benefits of management or treatment options Instructions and /or follow up Importance of compliance with chosen treatment and management options Instructions and/or follow-up Risk factor Reduction Patient and family education Note on Average Times For Consultation and Coordination of Care Times listed in the CPT code book are average times associated with each CPT code. Auditors often treat them as threshold times Ex: A has an average time of 25 minutes. Although not in the Documentation Guidelines, an auditor usually interprets 25 minutes or more supporting 99215, but less than 25 minutes not supportive of American Medical Association. Current Procedural Terminology CPT Chicago, Ill: AMA press;2013

34 Billing and Coding in Neurology and Headache American Headache Society (AHS) AHS s Headache Coding Corner ner.asp American Medical Association CPT-related resources Centers for Medicare and Medicaid Service (CMS) Evaluation and Management Services Guide Documentation Guidelines for Evaluation and Management Services

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