Michael Policar, MD, MPH, Presenter. Fundamentals of Family Planning Coding: Family Planning, Access, Care, and Treatment (Family PACT) and Medi Cal

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1 Michael Policar, MD, MPH, Presenter Fundamentals of Family Planning Coding: Family Planning, Access, Care, and Treatment (Family PACT) and Medi Cal January 15, 2014

2 What Is the Fundamental Objective of Coding? Provider To prepare a standardized bill for services given to a patient Payer To determine the amount to be paid to the provider (based on contracted rates). For medically necessary services. That are a benefit of the payer s health plan And supported by documentation 2

3 Codes Tell A Story What Encounter content Services performed Drugs, supplies provided Code book CPT 4 HCPCS II Why Diagnoses ICD CM 9 Additional Modifier CPT 4 Explanation To establish medical necessity, for every what there must be a why Unusual circumstances explained with a modifier 3

4 Coding Resources Medical services performed: CPT Current Procedural Terminology (4 th edition) Visits: Evaluation and Management (E/M) CPT codes Surgical procedures; diagnostic imaging; lab tests Developed and maintained by AMA Diagnoses: ICD 9 CM International Classification of Diseases 9 th Revision Clinical Modification Developed by WHO; maintained by CMS Procedures and supplies: HCPCS II National Codes Healthcare Common Procedure Coding System Developed and maintained by CMS 4

5 Annual CPT Code Update AMA Book On line CD ROM ipad, iphone, and Android platforms 5

6 CPT CPT Codes for Contraceptive Description Procedures 57170* Diaphragm, cap fitting 58300* Insert IUD 58301* Remove IUD 11976* Remove contraceptive implant 11981* Insert non biodegradable drug delivery implant Remove non biodegradable drug delivery implant Removal with reinsertion of non biodegradable drug delivery implant * Available codes in Family PACT and Medi Cal 6

7 Number codes for diseases and symptoms Major headings: xxx.x Subheadings: xxx.xx V codes for factors influencing health status and contact with health services Vxx.xx 7

8 On The Way.ICD 10 CM Expand from 14,000 (ICD 9) 68,000 codes!!! Official start date in U.S. is October 1, 2014 Medi Cal and Office of Family Planning (OFP) will participate in this code conversion Workshops are available on line, in person courses, and other venues 8

9 ICD CM Coding Rules List the principal diagnosis first, then others Code to the highest level of specificity (xxx.xx) In Family PACT, always include a V code for method used as the primary or secondary diagnosis Code the most specific description available at the completion of the visit If diagnosis is not established, code for symptom Don t code for rule out diagnoses Don t code a diagnosis that doesn t apply to the visit If visit for other than disease or injury, use V code 9

10 ICD 9 Codes for OCs, Patch Ring, DMPA Visits ICD 9 Code National code description Additional instructions V25.01 Prescription of OCs Initiation of OCs Surveillance of previously prescribed V25.41 methods; OC Unspecified V25.9 contraceptive management V25.40 Contraceptive surveillance, unspecified Follow up visit for oral contraceptive user Initiate patch, vaginal ring, or contraceptive injection Follow up visit for patch, ring or contraceptive injection user 10

11 ICD 9 Codes for Implants, IUC Visits ICD 9 National code description Additional instructions Code Insertion of implantable Insertion visit for V25.5 subdermal contraceptive subdermal implant Surveillance of previously Follow up visit for V25.43 prescribed methods; implant subdermal implant user V25.11 Encounter for insertion of IUD Insertion visit for IUC Surveillance of previously V25.42 prescribed methods; IUD Follow up visit for IUC V25.12 Encounter for removal of IUD Remove IUC Encounter for removal and V25.13 reinsertion of IUD Remove and reinsert IUC 11

12 ICD 9 Codes Barrier Methods and Natural Family Planning (NFP) ICD 9 Code V25.02 V25.49 V25.04 V26.41 National code description Initiation of other contraceptive measures Surveillance of previously prescribed methods; other contraceptive method Counseling and instruction in NFP to avoid pregnancy Procreative counseling and advice using NFP Additional instructions Initiate barrier method Follow up visit, barrier NFP to avoid pregnancy NFP to become pregnant 12

13 ICD 9 Codes for Contraceptive Sterilization ICD 9 Code V25.09 V25.2 National code description Encounter for contraceptive management, general counseling and advice; other Encounter for contraceptive management; Sterilization V26.51 Tubal ligation status V26.52 Vasectomy status Additional instructions Sterilization counseling and advice Sterilization procedure Routine postoperative management and surveillance Routine postoperative management and surveillance 13

14 ICD 9 Codes for Contraceptive Complications: Examples ICD 9 Code Interim code description National code description Vasovagal episode Syncope and collapse Pulmonary embolism with combined hormonal method DVT with combined hormonal method Heavy vaginal bleeding due to contraceptive injection Perforated or translocated IUD Female sterilization; operative site infection (< 30 days postop) Code must be billed with Contraceptive V code Pulmonary embolism V25.41 or V25.40 Acute venous thrombosis of lower extremity Excessive or frequent menstruation Mechanical complication due to IUD Other postoperative infection V25.41 or V25.40 V25.40 V

15 On site Dispensing of Drugs and Supplies 15

16 Family PACT: Contraceptive Supplies Interim Description HCPCS National Code Description Add l Instruct Condoms, male A4267 Condom, male each Condoms, female A4268 Condom, female, each Spermicidal gel/jelly/foam/cream A4269 U1 Spermicide (foam, gel), each U1 Spermicidal suppository A4269 U2 same U2 Spermicidal vaginal film A4269 U3 same U3 Spermicidal sponge A4269 U4 same U4 Lubricant S5199 Personal care item, NOS each Diaphragm, cervical cap, BBT thermometer No crosswalk Pharmacy dispensing only 16

17 Contraceptive Drugs and Devices Interim Description HCPCS National Code Description Add l Instruct Paragard IUD J7300 Copper IUD Mirena IUS J7302 Levonorgestrel IUD Skyla Q0090 Levonorgestrel IUD OC medications S4993 OCs for birth control Levonorgestrel EC (Plan B, Next Choice) Ulipristal Acetate (ella) J3490 U6 J3490 U5 Unclassified drugs Unclassified drugs Modifier U6 Modifier U5 Norelgestromin/EE transdermal patch J7304 Contraceptive supply, hormone patch, each Etongestrel/EE vaginal ring J7303 Contraceptive supply, hormone containing vaginal ring, each Misc drugs (for nonsurgical procedures) S5000 S5001 Prescription drug, brand name Prescription drug, generic NDC required on the claim 17

18 Education and Counseling (E&C) Codes Interim Code National National Code Description Additional Description Code Instruction s Family PACT, group S9446 Patient education, non FP education physician provider, group, per session Family PACT, S9445 Patient education, nonindividual FP physician provider, individual, education, <10 min per session Family PACT, 99401U6 Preventive medicine Use U6 to individual family counseling and/or risk factor indicate planning education, reduction intervention(s) Family up to 15 minutes provided to an individual: PACT E&C approximately 15 minutes services minutes 99402U6 approximately 30 minutes same minutes 99403U6 approximately 45 minutes same 18

19 Provider Type Modifiers Medi Cal, including Family PACT Provider type Physician Nurse practitioner Certified nurse midwife Physician assistant Registered nurse Modifier AG SA SB U7 TD 19

20 Coding Case Studies 20

21 Outpatient Coding: Basic Questions Is the patient new or established? Which procedures were done? (CPT and/or HCPCS II codes) Office surgical procedures Supplies for certain procedures (UA/UB) Drugs or devices administered or dispensed on site Office lab tests or imaging studies Which visit type and level of E/M or E&C code? Time or history, physical, medical decision making Which modifiers are necessary? What is the (ICD 9) diagnosis for each CPT (+E/M)? 21

22 Case Study 1: Oral Contraceptive Refill Ms. A is a 28 year old new client requesting refill of OCs Mutually monogamous for 4 years PMH negative, normal LMP 2 wks ago, non smoker Detailed history (extended HPI, ROS + pertinent PFSH) Weight: 175 lbs, Height: 5 3, normal BP Breast and pelvic exam; cervical cytology sample sent Detailed examination (12 bullets) Prescription for EE 20 mcg + LNG 100 mcg given Records from prior clinician requested Medical decision making: moderate complexity Visit took 18 minutes; 7 minutes spent counseling 22

23 Problem Oriented E/M Visits Either: HISTORY TIME EXAM MEDICAL DECISION MAKING Composite of 3 key components (Hx + PE + MDM) Or TIME, when greater than 50% of time is spent in counseling 23

24 Problem Visit E/M Structure E/M Levels History (4) Physical (4) MDM (4) Time HPI (8 elements; 2 levels) ROS ( 14 systems; 3 levels) PFSH (3 areas; 2 levels) Single organ system OR Multiple organ sys (bullets) Diagnoses (4 levels) Data Complexity (4 levels) Risk of Complication (4 levels) 24

25 E/M Visit: History New Patient Office Visits 25

26 E/M Visit: History Established Patient Office Visits Level HPI ROS PFSH Minimal Not required Not required Not required Problem focused Expanded Problem Focused Brief 1 3 elements Brief 1 3 elements Not required Pbm Pertinent (1 system) Not required Not required Detailed Extended Extended Pertinent 4+ elements 2 9 system any 1 of 3 Comprehensive Extended 4+ elements Complete systems Complete Any 2 of 3 26

27 E/M Visit: Single Organ Exam Female Genitourinary Exam: 11 elements Inspection and palpation of breasts Digital rectal exam Pelvic exam External genitalia Cervix Urethral meatus Uterus Urethra Bladder Adnexa/parametria Anus and perineum Vagina 27

28 E/M Visit: Physical Examination (Medicare 1997 Documentation Guidelines) Level Problem Focused Expanded Problem Focused Single Organ System Exam 1 5 bullet elements 6 11 bullet elements Detailed Comprehensive > 12 bullet elements 7/11 female GU exam bullets plus: abdomen, constitutional plus: 1 each of neck, respiratory, CV, lymph, skin, & neuro/psych 28

29 E/M Visit: Medical Decision Making Two of three elements must be met or exceeded Level # Diagnoses, Mgt options Data amt/ complexity Risk of Complications Straightforward Minimal (1) Minimal Minimal Low Limited (2) Limited Low Complexity Moderate Multiple (3) Moderate Moderate Complexity High Complexity Extensive(4) Extensive High 29

30 Summary: Problem Oriented E/M 1. Score E/M level based on key components Score history Score physical exam Score medical decision making Choose E/M based on 3 key components 2. Compute counseling time as a % of face to face time If >50% of visit, choose E/M based on time factor 3. Select the E/M code that is greater of 3 key components or face to face time 30

31 E/M Coding: New Patient Office Visit Lesser component determines level of care E/M History Exam MDM PF PF Straightforward EPF EPF Straightforward Detailed Detailed Low complexity Comprehensive Comprehensive Comprehensive Comprehensive Mod complexity High complexity 31

32 E/M Coding: Established Patient Office Visit Need 2/3 Key Components E/M History Exam MDM N/R N/R N/R PF PF Straightforward EFP EPF Low complexity Detailed Detailed Mod complexity Comprehensive Comprehensive High complexity N/R: Not required 32

33 Case Study 1: Answer Procedure Supplies Drug Lab CPT Code None None None; pharmacy will bill for OCs dispensed None; lab will bill for cervical cytology ICD CM Code E&M V25.41 (Contraceptive surveillance: OC) Modifier SA 33

34 Case Study 2: Family Planning Health Screening Ms. B, a 17 year old established patient seen for initiation of contraception and check up Menses are regular; no complaints Sexual debut 6 months ago; 2 lifetime partners BP checked; urine sample for chlamydia NAAT FTF time: 25 min (5 min counselor, 20 min NP) Total counseling time: 18 minutes Dispensed 9 norelgestromin/ethinyl estradiol transdermal patches 34

35 Problem Oriented E/M: Face to Face Time E/M Typical time E/M Typical time new (min) established (min)

36 Problem Oriented E/M: Face to Face Time Midpoints New Time (typical) < 15 (10) (20) (30) (45) > 53 (60) Established Time (typical) < 7 (5) (10) (15) (25) >33 (40) 36

37 Case Study 2: Answer Procedure Supplies Drug Lab CPT/HCPCS II Code None None J7304 (patchx9 units) None; lab will bill for chlamydia NAAT test ICD CM Code E&M V25.9 Unspecified contraceptive management Modifier SA Family PACT does not include Preventive Medicine check up codes: (new); (established) 37

38 Case Study 3: A New Patient Family Planning Visit Ms. C, a 19 year old new client is seen in a family planning clinic to discuss contraception She started sexual activity 2 months ago and had unprotected intercourse 3 days ago A health educator spent 24 minutes discussing contraceptive options, STI protection, and ECPs Individual orientation to Family PACT was provided Chlamydia/GC NAAT test sample sent to lab A clinician prescribed and dispensed 1 pack of levonorgestrel EC and dispensed 20 condoms 38

39 Case Study 3: Answer CPT/HCPCS II Code ICD CM Code Procedure Supplies Drug Lab E&C Codes Modifier None A4267 (male condom) x20 J3490U6 (LNG ECP) X1 None; lab will bill for chlamydia NAAT test S9445 (Patient ed, NEC) S99402U6 (Prev medicine counseling, approx. 30 min U6 as above V25.02 (initiation of other [barrier] contraceptive) 39

40 Case Study 4: Implant Removal Mrs. D is an established client who had a contraceptive implant placed 2 years ago She requests removal of the implant so that she can become pregnant The physician provides 15 minutes of counseling about timing intercourse to achieve pregnancy and preconception counseling, then removes the implant 40

41 Office Surgical Procedures Procedure CPT includes Brief focused history Checking use of medications and allergies Administration of local anesthesia Performance of procedure Post operative observation Bill only the procedure CPT code when Counseling provided was in the context of the procedure Other cognitive services given on same day did not require significant history, exam, or medical decision making 41

42 Office Surgical Procedures Procedure + E/M visit on same day May also bill E/M if patient requires a significant, separately identifiable E/M service Apply modifier 25 (distinct E/M services) to E/M ICD 9 diagnosis codes should be different for CPT, E/M Payment policies Some will pay both CPT + E/M, with same ICD 9 code Some will pay E/M only if a separate diagnosis from CPT Others will pay either the E/M or the CPT 42

43 Case Study 4: Answer CPT/ HCPCS II Code Procedure (implant removal) Supply Drug Lab No No No E/M (established, 15 min) Modifier , AG ICD CM Code V25.43 (surveillance, implant ) V26.41 Procreative counseling and advice using NFP Use two separate claim forms for the 2 different contraceptive codes 25 indicates that a significant and separately identifiable E/M was provided on the same date of service as a procedure 43

44 Case Study 5: Implant Removal with Reinsertion Ms. E has had an implant for 3 years She is not planning on having a child for 3 5 years, and would like another implant The physician asks a few questions about any problems with the implant; Ms. E signs a consent form The physician removes the old implant and inserts a new one all during this one visit 44

45 Case Study 5: Answer Procedure CPT Code (insertion, non biodegradable drug delivery implant) (removal, implantable contraceptive capsules) ICD CM Code V25.43 (Surveillance, implant) Supply Drug Lab E/M None; included in J code J7307 (Etonogestrel implant) None None Modifier AG, No E/M services are reported for the brief discussion with the client prior to the removal and reinsertion procedures 45

46 Case Study 6: IUD Removal and Implant Insertion Ms. F had an IUD inserted 5 years ago but is now experiencing bleeding and cramping The NP does an expanded problem focused exam and takes additional history They discuss removal of the IUD and other possible contraceptive methods for 10 minutes After a brief discussion, Ms. F requests a placement of a contraceptive implant The clinician removes the IUD and inserts an implant 46

47 Case Study 6: Answer CLAIM #1 CPT/ HCPCS II Code ICD CM Code Procedure (implant insertion) V25.5 (implant insertion) Supplies Supplies for implant insertion are included in the CPT code Drug Lab J7307 (ETG implant) None E/M V25.5 (implant insertion) Modifier , SA In Family PACT, two claim forms must be submitted because of two different contraceptive diagnoses E/M code for contraceptive counseling may be submitted 47

48 Case Study 6: Answer CLAIM #2 CPT/ HCPCS II Code ICD CM Code Procedure (IUD removal) V25.42 (IUD removal) Supplies 58301UA (IUD removal) Drug None Lab None E/M None Modifier Modifier 51 (multiple procedures) is added to the lesser procedure Modifier 99 (multiple modifiers): in remarks box, enter SA

49 Case Study 7: Routine DMPA Injection Ms. G, a 24 year old established patient seen for DMPA injection DMPA is stocked on site Very short history update by a LVN, then IM injection of DMPA 150 mg. given 49

50 E/M Coding: Established Patient Office Visit The Visit Nurse, tech, medical assistant, counselor sees patient at clinician request Examples: BP check, review medications, provide injection (e.g., vaccine, DMPA), and patient education Used only for established patients Must document visit, but not key components or time Medicare requires that a clinician be on site (but not CPT) 50

51 Case Study 7: Answer Procedure Supplies CPT Code None None Drug J1050 (DMPA, 150 units) Lab None ICD CM Code E/M V25.40 (surveillance BCM) Modifier None For DMPA 150 mg, the code J1050 replaced the end dated J1055 code on 9/1/13 To calculate the new DMPA payment rate, refer to the Medi Cal manual Part II for instructions on the administration fee 51

52 Case Study 8: RN Billing with TD Modifier Ms. J is a 27 year old female established patient seen for a refill of her oral contraceptives She is seen by an RN who is following a standardized protocol for provision of hormonal contraceptives Her medical history is unremarkable and she has no US MEC category 3 or 4 conditions Her BP is normal She is dispensed 13 cycles of generic monophasic OCs + 24 condoms for back up by the RN 52

53 Case Study 8: Answer Procedure Supplies Drug Lab CPT/ HCPCS II Code None A4267 (condoms) x24 S4993 x 13 cycles None ICD CM Code E/M V25.41 (OC surveillance) Modifier TD 53

54 Case Study 9: Start OCs and a UTI Diagnosis Ms. H has an initial family planning office visit, which includes a history, physical exam and counseling about all contraceptive methods A pregnancy test is performed in house because of late period A dipstick urinalysis is performed in the office for symptoms of urinary tract infection (UTI) A blood specimen for glucose is drawn in the office and sent to an outside laboratory due to family history of diabetes, high BMI The client is given a prescription for OCs and an antibiotic The clinician PA dispenses condoms and foam for quick start 54

55 Case Study 9: Answer Procedure Supplies Drug CPT/ HCPCS II Code (blood draw) A4267 (condoms) A4269 U1 (foam spermicide) None ICD CM Code Lab (pregnancy test) (UA dipstick, no microscopy) (acute cystitis) E&M V25.01 (initiate OCs) Modifier U7 55

56 Case Study 10: Screen Me For Everything Ms. K is a 28 year old established patient is seen by CNM for a refill of her vaginal ring prescription She also requests STI screening she is asymptomatic Unprotected sex with new partner 6 weeks ago Pelvic exam negative; sampled for GC, Chlamydia Microscopy: negative for candida, trich, BV Vaginal ph: 4.0 Blood drawn for syphilis and HIV screening CNM dispenses four contraceptive vaginal rings (CVR) 56

57 Case Study 10: Answer CPT code Procedure Supplies Drug Lab None J7303 (ring) x4 Q0111 (wet mount) (vaginal ph) ICD CM code V01.6 (exposure to STD) E/M V25.9 (unspecified contraceptive management) Modifier SB * CPT 99000: handling or conveyance of blood specimen for transfer to lab 57

58 Case Study 11: Colposcopy Ms. L is 24 year old established client was seen 3 weeks ago for a family planning health screening visit Cervical cytology result returned high grade SIL (HSIL) Using Copper IUC without problems Colposcopy procedure explained; consent obtained Colposcopy performed, with 1 cervical biopsy and ECC 58

59 CPT Codes for Colposcopy CPT Procedure Vulvar colpo only (56821: with biopsy) Vaginal colpo only (57421: with biopsy) 57452* Cervical colposcopy only 57454* Cervical colpo with biopsy & ECC 57455* Cervical colpo with biopsy 57456* Cervical colpo with ECC ECC only 58100* Endometrial biopsy 58110* Cervical colposcopy with endometrial biopsy * Available codes in Family PACT 59

60 ICD 9 CM Codes for Cervical Conditions Cytology Diagnoses ICD 9 AGC * ASC US * ASC H * LSIL * HSIL * Abnormal Pap, HPV + Other abnormal Pap * * Leukoplakia, cervix 622.2* Biopsy Diagnoses ICD 9 Dysplasia, NOS CIN I * CIN II * CIN III 233.1* Endocervix cancer Exocervix cancer Cervix cancer NOS * Available codes in Family PACT 60

61 Case Study 11: Answer CPT code Procedure (colpo + biopsy + ECC) ICD CM code (HSIL on Pap) V25.42 (IUC surveillance) Supply Drug Lab in house E/M Modifier 57454UA None None None AG 61

62 Case Study 12 Same patient as last case, but also complains of vaginal and vulvar itching Before colposcopy, vaginal samples taken, office microscopy done; diagnosis = candidiasis Dispensed clotrimazole cream Questions: Which additional codes should be added? Is a modifier necessary? 62

63 Case Study 12: Answer Claim #1 CPT code ICD CM code Procedure (colpo + biopsy + ECC) (HSIL on Pap) V25.42 (IUC surveillance) Supply Drug Lab in house E/M Modifier UA None None None AG UA 63

64 Case Study 12: Answer Claim #2 CPT code ICD CM code Procedure None Supply Drug Lab None (clotrimazole x1 tube) Q0111 (office wet mount) E/M (VV candidiasis) V25.42 (IUC surveillance) Modifier indicates that a significant and separately identifiable E/M service was provided on the same day as a procedure 64

65 Familypact.org/providers PPBI Bulletins 65

66 Additional Resources: Coming Soon Updated Family PACT Superbill (December 2013) Family PACT Benefit Update: 2013 webinar New Provider Orientations Watch for Family PACT Bulletin Updates released on the 15 th of each month ( Cal.ca.gov; Publications; Bulletins; Family PACT) Sign up for the Medi Cal Subscription Service to get all updates 66