School Based Health Care Coding at Your Best

Transcription

1 School Based Health Care Coding at Your Best Presented by Carley Spangler, CPC Account Manager, OCHIN Billing Services October 2011 OCHIN 707 SW Washington Suite 1200 Portland, OR P F

2 OBJECTIVES At the end of this presentation you will have knowledge on: Code selection- Choosing the correct LOS Preventive visits Correct billing for VFC (vaccines for children) Billing of CCARE Knowing when a DX code is covered or not When to use MOD 25

3 EVALUATION AND MANAGEMENT

4 New Patient VS. Established Patient New Patient O/V One who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years Example- - A patient is seen 08/15/2003 and comes back 07/30/2007 they would be considered a New Patient - A patient is seen for the very first time at your clinic. - A patient is seen by their PCP at Family Health care and is referred to a Dermatologist in the same clinic, the first encounter with Dr. Johnson(dermatologist) is a new patient visit.

5 Established Patient Visit Definition of Established Patient- A patient who has been seen within the last three years. Common Denial- patient no longer qualifies as New patient.

6 Three Key components to Code selection The extent of the history. The extent of the physical examination. The complexity of the medical decision making. This needs to be one of the components at the level of the visit selected.

7 HISTORY COMPONENT- HPI History of present illness ROS Review of systems PFSH Past Family Social History EXAM COMPONENT- Body Areas Organ Systems

8 MEDICAL DECISION MAKING Straightforward- levels 1 or 2 Very few DX codes, illness that can be taken care of at home. Low complexity- level 3 Prescribe an OTC medication or a refill Moderate Complexity- level 3 or 4 Prescription for a new problem or the worsening of an existing problem High Complexity- level 5 Admission to hospital or surgery from your clinic. exacerbation of existing problem.

9 E &M Cheat Sheet

10 Coding by Time For most E&M codes, time is not a factor. If more than one half of a visit is spent in counseling, then time becomes the determining factor and the KEY COMPONENT! Both the actual time for the visit and the actual time spent in counseling must be documented Time is counted as face-to-face physician time in the office and outpatient settings and unit/floor time in the hospital.

11 BREAKDOWN OF TIME Face-To-Face Time minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes

12 Preventative Care New Patient AGE Established Patient under 1 year old years years years

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14 DIAGNOSIS CODES Preventative Diagnosis Codes- V70.0 would be used for person over 18 V20.2 for under 18 Billable diagnosis codes- V codes Unspecified codes Signs and symptoms Code to the highest specificity

15 DIAGNOSIS CODES MMIS- Medicaid Management Information System ICD-9 t10icd_9.pdf CPT t10cpt.pdf

16 VFC VACCINES FOR CHILDREN

17 The Vaccines for Children Program (VFC) is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. Example claim form for billing VFC MODIFIER SL MODIFIER 26

18 OREGON CONTRACEPTIVE CARE CCare

19 The Purpose of CCare To improve family well-being Reduce unintended pregnancies Increase access to health care Provide contraceptives & Family planning services

20 CCare Reimbursement $140 per encounter Acquisition cost of supplies $440 for vasectomies (men 21 & older) Vasectomy provider receives $440 Includes post-vasectomy sperm count Referring FP agency can bill $140 for prevasectomy counseling visit CCare rate is higher than OHP rate

21 CCare Billing T015- FP Supply codes Example of a CCare claim

22 Who is Eligible Reproductive age Resident of Oregon Income below 185% Federal Poverty Level U.S. citizen, or Lawful Permanent Resident for at least 5 years Eligibility effective for 12 months regardless of changes in income, FPL or insurance

23 MODIFIER -25

24 Definition-Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service -Always append the MOD 25 to the E/M code. Example: office visit preventive care

25 MODIFIER -25 Questions to ask yourself regarding MOD -25 Is there a different diagnosis as the reason for multiple services at the same visit? If not, do I have enough documentation to prove the extra service was needed?

26 QUESTIONS?? THANK YOU FOR YOUR TIME! Carley Spangler, CPC 707 SW Washington Street Suite 1200 Portland OR Phone Fax: