Jon Hathaway, MD PhD 4:00-5:00 pm Feb 1, Coding Made Easy. Coding for Cash And to avoid the penitentiary. Jon K. Hathaway, MD, PhD.

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1 Coding Made Easy Coding for Cash And to avoid the penitentiary Jon K. Hathaway, MD, PhD Objectives Review Coding Documentation Guidelines Review the Global Package Discuss ICD-9 and ICD-10 Review Inpatient coding (time permitting) MSACOG Snow Meeting 1

2 How does your office determine coding level for E&M visits? 1. I code it. 2. Someone in my office codes it. 3. The EMR codes it. 4. I always bill a (whatever that is). 5. Other I code it. 0% 0% 0% 0% 0% Someone in my... The EMR codes... I always bill... Other Purpose of Coding To $tandardize the de$cription of the patient $ $ymptom or di$ea$e proce$$. To allow for retro$pective re$earch to evaluate outcome$, intervention$, etc. To evaluate quality of care. To evaluate what procedure$ are being performed for which diagno$e$ MSACOG Snow Meeting 2

3 Types of Codes ICD-9/10: Identifies diseases or symptoms. International Classification of Disease. CPT-4: Identifies procedures performed. Current Procedural Terminology. ICD ICD does not allow you to code for rule out, suspected or Probable conditions indicate a symptom if you don t have a specific diagnosis. Use only current conditions that are the reason for the visit (if you don t treat or address the HTN or hypothyroidism, then don t code it) MSACOG Snow Meeting 3

4 Evaluation & Management coding (E&M) Types of visits Problem visit New Established (seen by practice or Dr in last 3 years) Consultation Preventative New Established Age Ranges What is the definition of outpatient? 1. Anyplace that isn t inpatient-duh! 2. Only outpatient office buildings not attached to a hospital. 3. Only private office space, attachment to hospital unimportant. 4. Only private office space and emergency rooms, everywhere else is inpatient. 0% 0% 0% 0% MSACOG Snow Meeting 4

5 History Exam Assessment Plan Elements of a Visit Elements of a Visit History Chief Complaint History of Present Illness (HPI) Past Medical, Family and Social Hx (PSFH) Review of Systems (ROS) Examination 1995 & 1997 guidelines Medical Decision Making Number of Diagnoses Amount/Complexity of Data or Mortality Risk of Complications or Morbidity 2013 MSACOG Snow Meeting 5

6 Elements of a Visit History Chief Complaint (reason for the visit doesn t have to be a complaint) HPI: Elements Location Quality Severity Duration Timing Context Modifying Factors 2 types brief or extended. Brief has 1-3 elements Extended has 4+ elements Extended can also be 3 chronic or inactive conditions. Mrs. A c/o vaginal bleeding, heavy (could use pad count), lasting 5-7 days every 28 days for the last 6 months. Seem to be better when on OCP s. History Level HPI ROS PFSH Problem Focused Brief None None Expanded PF Brief 1 None Detailed Extended Comprehensive Extended MSACOG Snow Meeting 6

7 ROS Elements of a Visit 12 areas: Constitutional, Eyes, ENT, CV, Pulm, GI, GU, MS, Integumentary, Neuro, Psych, Endo, Heme/lymph, Allergy. One system: Expanded Problem Focused 2-9 systems: Detailed 10+ systems: Comprehensive Any problems with your bowels or bladder? History Elements of a Visit PFSH (Past, Family, Social History) One element: Pertinent 2+: Complete 2013 MSACOG Snow Meeting 7

8 History Mrs. A c/o amenorrhea for 6 months, has been irregular since age 18 when she gained a lot of weight. Normal menses when on OCP s. Also c/o facial hair and a dirty neck. No Bowel or Bladder Issues Past Medical History significant for obesity and infertility despite trying. History Level HPI ROS PFSH Problem Focused Brief None None Expanded PF Brief 1 None Detailed Extended Comprehensive Extended MSACOG Snow Meeting 8

9 Moving On Exam 1995 Guidelines: Not good for basic OB/GYN so fought for new guidelines!! 1997 Guidelines: EXCELLENT!! 2013 MSACOG Snow Meeting 9

10 Elements of an Exam Constitutional: 3 vitals (BP, Pulse, Resp, Temp, Ht, Wt) General Appearance GI: Exam of Abdomen (masses, tenderness) Exam of Liver and Spleen Occult blood (if indicated) Hernia Elements of an Exam GU Breast Exam Digital Rectal Exam External Genitalia Meatus: location, prolapse, lesions. Urethra: masses, tenderness, scarring. Bladder: fullness, masses, tenderness. Vagina: support, estrogen, discharge, lesions Cervix: appearance, lesions, discharge Uterus: size, contour, mobility, position, support Adnexa: mass, tenderness, organomegaly Anus/Perineum 2013 MSACOG Snow Meeting 10

11 Elements of an Exam Neck: Thyroid General Exam Respiratory Effort Auscultation CV Auscultation Peripheral Vascular System (varicosities, swelling, pulses, edema, tenderness) Lymphatic Palpation of lymph nodes: neck, axillae, &/or groin. Skin Inspection and Palpation (rash, lesion, ulcer) Neuro/Psych Orientation Mood/Affect Four Types Exam Problem Focused: 1-5 elements Expanded PF: 6-11 elements Detailed: 12+ elements Comprehensive: Let s Talk MSACOG Snow Meeting 11

12 Comprehensive Exam All Consitutional: 3 vitals, general appearance. All GI: Exam, liver/spleen, occult blood, hernia Any 7 GU elements One element from: Neck: Thyroid General Exam Respiratory CV Effort Auscultation Auscultation Peripheral Vascular System (varicosities, swelling, pulses, edema, tenderness) Lymphatic Skin Palpation of lymph nodes: neck, axillae, &/or groin. Inspection and Palpation (rash, lesion, ulcer) Neuro/Psych Orientation Mood/Affect 1995 Guidelines Body Areas Organ Systems Head Neck Chest/Breast Abdomen Genitalia/Buttocks Back/Spine Extremities Constitutional Psych Skin ENMT Eyes Neuro Respiratory GI Heme/Lymph Musculoskeletal GU Cardio 2013 MSACOG Snow Meeting 12

13 1995 Guidelines Problem Focused 1 element Expanded PF 2-4 elements Detailed 5-7 elements Comprehensive 8+ elements All of the following body parts get bigger with age except? 1. Feet 2. Nose 3. Ears 4. Genitalia 0% 0% 0% 0% MSACOG Snow Meeting 13

14 Here Comes the Hard Part Medical Decision Making Straightforward Low Complexity Moderate Complexity High Complexity Number of Diagnoses or Management Options Amount or Complexity of Data to Review Risk of Complications or Morbidity/Mortality Medical Decision Making Diagnoses Minimal Limited Multiple Extensive Data Minimal Limited Moderate Extensive Risk Minimal Low Moderate High Straight Forward Low Complexity Moderate Complexity High Complexity 2013 MSACOG Snow Meeting 14

15 Number of Diagnoses Self-Limited or Minor: Established Problem, stable: Established Problem, worsening: New Problem, No additional w/u: New Problem, additional w/u: 1 point 1 point 2 points 3 points 4 points Minimal: Limited: Multiple: Extensive: 1 point 2 points 3 points 4 points Amount/Complexity of Data Review/Order lab tests or procedure: 1 point Radiology or Medical arena Discussion of diagnostic test results w/ performing physician: 1 point Decision to obtain old records &/or Obtaining history from someone other than patient: 2 points Review and summary of old records &/or Obtaining history from someone other than patient &/or Discussion of case with another provider: 2 points Independent visualization of image/tracing/specimen: 2 points Minimal: 1 point Limited: 2 points Multiple: 3 points Extensive: 4 points 2013 MSACOG Snow Meeting 15

16 Level of Risk Minimal: One self-limited or minor problem/cxr/superficial dressing. Cold, insect bite, tinea corporis. UA, Wet Mount, blood tests, U/S ordered Rest, Ace bandage Low: One stable chronic illness/superficial needle bx/otc Rx. Acute, uncomplicated illness or injury Arterial blood tests, Imaging studies with contrast (SIS) Minor surgery with no identified risk factors, IV fluids Moderate: One or more chronic illnesses w/ mild exacerbation, progression or side effects/diagnostic endoscopies w/ no identified risk factors. New problem with uncertain prognosis (breast lump), 2 stable chronic illness (DM and HTN), Acute illness w/ systemic sx, acute, complicated injury Fetal STRESS test, CV imaging, Deep needle or incisional bx (including culdocentesis Minor surgery with risk factors, Elective major surgery w/o risk factors, Management of prescription drugs, IV fluids with additives High: Acute or Chronic illnesses or injuries that pose a threat to life or bodily function/diagnostic endoscopies w/ identified risk factors/emergency major surgery. Abrupt change in neuro status CV imaging with risk factors, Dx endoscopies with risk factors Elective or emergency major surgery with risk factors, drug therapy requiring intensive monitoring for toxicity. Level of Risk Minimal: One self-limited or minor problem/cxr/superficial dressing. Wet Mount Rest Low: One stable chronic illness/otc Rx. Imaging studies with contrast (SIS) Minor surgery with no identified risk factors IV fluids Vaginitis Renewal of HRT/OCP 2013 MSACOG Snow Meeting 16

17 Level of Risk Moderate: One or more chronic illnesses w/ mild exacerbation, progression or side effects/diagnostic endoscopies w/ no identified risk factors. New problem with uncertain prognosis (breast lump) Irregular bleeding Diagnostic endoscopies w/ no identified risk factors Minor surgery with risk factors Elective major surgery w/o risk factors Management of prescription drugs IV fluids with additives High: Acute or Chronic illnesses or injuries that pose a threat to life or bodily function/diagnostic endoscopies w/ identified risk factors/emergency major surgery. Dx endoscopies with risk factors Pelvic Pain Multiple complaints Elective or emergency major surgery with risk factors Drug therapy requiring intensive monitoring for toxicity. Medical Decision Making Number of Diagnoses or Management Options Amount or Complexity of Data to Review Risk of Complications or Morbidity/Mortality Only need 2 out of 3!! 2013 MSACOG Snow Meeting 17

18 Medical Decision Making Diagnoses Minimal Limited Multiple Extensive Data Minimal Limited Moderate Extensive Risk Minimal Low Moderate High Straight Forward Low Complexity Moderate Complexity High Complexity When was insemination without intercourse discovered? 1. Soranus (98BC) 2. Talmud (200AD) 3. Arabs (1500AD) 4. Jacobi (1764) 0% 0% 0% 0% Soranus (98BC) Talmud (200AD) Arabs (1500AD) Jacobi (1764) 2013 MSACOG Snow Meeting 18

19 New Patient Level 1 Level 2 Putting it all together History Exam Medical Decision Making Problem Focused Problem Focused Straight Forward Expanded Problem Focused Expanded Problem Focused Straight Forward Level 3 Detailed Detailed Low Complexity Level 4 Comprehensive Comprehensive Moderate Complexity Level 5 Comprehensive Comprehensive High Complexity Putting it all together Established Patient: Only Need 2 of 3!! Level 1 History Exam Medical Decision Making Level 2 Problem Focused Problem Focused Straight Forward Level 3 Expanded Problem Focused Expanded Problem Focused Low Complexity Level 4 Detailed Detailed Moderate Complexity Level 5 Comprehensive Comprehensive High Complexity 2013 MSACOG Snow Meeting 19

20 Putting it all together Initial Consultation Level 1 Level 2 History Exam Medical Decision Making Problem Focused Problem Focused Straight Forward Expanded Problem Focused Expanded Problem Focused Straight Forward Level 3 Detailed Detailed Low Complexity Level 4 Comprehensive Comprehensive Moderate Complexity Level 5 Comprehensive Comprehensive High Complexity Putting it all together Time-based Billing New Patient Established Consultation Level Level Level Level Level MSACOG Snow Meeting 20

21 Preventative Visits Requirements based on age. Payment for Hx and PE only (no MDM) No specified elements of the exam. Must document a multisystem exam. For us includes breast and pelvic +/- Pap smear. No need for CC or HPI. Includes counseling such as contraception, safety, need for screening tests, BSE, vaccines, etc. Can bill for problem-based service if provided at the same time (and documentation supports this). May not get paid though. ACOG suggests billing whichever takes the most time. Can also break up the visit into two visits. Patient may have a copay for E&M visit. Most payers will not pay for 2 annual exams in one year. Medical Students Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable). You, the student, may document services in the medical record; however, the teaching physician may only refer to your documentation of an E/M service that is related to the ROS and/or PFSH. The teaching physician may not refer to your documentation of physical examination findings or medical decision making in his or her personal note. If you document E/M services, the teaching physician must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision making activities of the service MSACOG Snow Meeting 21

22 Who first recorded that intercourse was necessary for pregnancy? 1. Hippocrates (400BC) 2. Aristotle (350BC) 3. Soranus (98BC) 4. Galen (200AD) Hippocrates (4... 0% 0% 0% 0% Aristotle ( Soranus (98BC) Galen (200AD) Any Questions? 2013 MSACOG Snow Meeting 22

23 CHIEF COMPLAINT: Chronic pelvic pain. The patient is referred to Dr. X for an evaluation of her pelvic pain. HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 22-year-old Caucasian female G zero whom I have been following in the clinic for several visits now who has a history of longstanding chronic pelvic pain. Occurs most days and lasts all day. Stabbing mostly. Mainly located behind the symphysis pubis. No relief with voiding or BM. Non-cyclical. +dyspareunia. ROS: No Bladder or Bowel problems except GERD. PAST MEDICAL HISTORY: Significant for gastroesophageal reflux disease. PAST SURGICAL HISTORY: Tonsillectomy, adenoidectomy in 2007, as well as, diagnostic laparoscopy in 05/2008. GYNECOLOGIC HISTORY: The patient does have a history of abnormal Pap smear in 04/2008 which I believe was a low grade squamous intraepithelial lesion. She followed up for colposcopy and had no procedures. Menarche onset at age 16, every 28 days lasting up to five days with moderate flow, however, associated with significant dysmenorrhea. The patient currently is on the Alesse birth control pills with continued cramping. The patient is sexually active. Has a positive history of Chlamydia and PID 01/2008. SOCIAL HISTORY: Negativex3. She does have a boyfriend. Negative tobacco and illegal drugs. The patient admits to occasional social drinking a drink approximately twice a month. FAMILY HISTORY: Noncontributory. What is the History Level? 1. Problem Focused 2. Expanded PF 3. Detailed 4. Comprehensive 0% 0% 0% 0% Problem Focuse... Expanded PF Detailed Comprehensive 2013 MSACOG Snow Meeting 23

24 PHYSICAL EXAMINATION: On examination 150 pounds, blood pressure 106/70, Pulse 72. GENERAL: NAD. No anxiety. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, nontender, nondistended. GENITOURINARY: External genitalia within normal limits. Vaginal wall, urethra and anus normal. Pelvic examination a small, anteverted, mobile uterus with normal adnexal examination. No acute tenderness to palpation. The patient's hemoglobin in 05/ and hematocrit of 36. Last gonorrhea, chlamydia cultures 10/10/2008 both negative. The patient did have an ultrasound done in 11/2008 at which point the uterus measures 6.7 x 3.4 x 4.7 cm, right and left ovaries within normal limits. The right ovary contained a simple cyst measuring 2.2 x 1.1 x 1.4 cm, left ovary was within normal limits. There was free fluid seen around both ovaries sounds. What is the Physical Exam? 1. Problem Focused 2. Expanded PF 3. Detailed 4. Comprehensive 0% 0% 0% 0% Problem Focuse... Expanded PF Detailed Comprehensive 2013 MSACOG Snow Meeting 24

25 ASSESSMENT/PLAN: The patient is a 22-year-old Caucasian female G0 with troubling psychiatric history, as well as, continued vague, fluctuating complaints of pelvic pain, possibly component of a gastrointestinal trouble. I discussed with the patient expectant management versus Depo- Provera. She would like to try depoprovera. I would like her to be evaluated by Dr. X. The patient was very open to the idea of seeing Dr. X. Given the findings on the ultrasound of fluid around the ovaries, a repeat ultrasound may be useful should she not improve here in the meantime. The examination does not support an abscess or tubo-ovarian process at this point. Medical Decision Making? 1. Straightforward 2. Low 3. Moderate 4. High 0% 0% 0% 0% Straightforwar... Low Moderate High 2013 MSACOG Snow Meeting 25

26 What is the overall code? 1. Level 1 2. Level 2 3. Level 3 4. Level 4 5. Level 5 0% 0% 0% 0% 0% Level 1 Level 2 Level 3 Level 4 Level 5 Phew!! So who really cares and can you get away with a few incorrect codes? I m just too tired to worry about this and so I just code a level 2 visit for everything (this will cost you more than $50K/year). ARRGGHH!! 2013 MSACOG Snow Meeting 26

27 RVU differences Established Patient OUTPATIENT VISIT, RET OUTPATIENT VISIT, RET OUTPATIENT VISIT, RET OUT-PATIENT VISIT, RET 1.77 New Patient OUT PATIENT VISIT NEW OUTPATIENT VISIT NEW OUTPATIENT VISIT NEW OUT-PATIENT VISIT NEW OUT PATIENT VISIT NEW 2.67 Rough estimate of Medicare RVU= $37. Private Insurance RVU= $60. Besides humans, what other animal has sex for pleasure only? 1. Porcipines 2. Chimps 3. Elephants 4. Dogs 5. Dolphins 0% 0% 0% 0% 0% Porcipines Chimps Elephants Dogs Dolphins 2013 MSACOG Snow Meeting 27

28 ICD-10 Was supposed to start October 1, 2013 but was pushed back to October 1, Many codes will have the same name but there will be some differences especially for OB. Currently a freeze on ICD-9 changes. ICD MSACOG Snow Meeting 28

29 ICD-10 ICD-9 Molar Pregnancy: 630 Hydatidiform mole Trophoblastic disease NOS Vesicular mole ICD-10 Molar Pregnancy O01.0 Classical hydatidiform mole O01.1 Incomplete and partial hydatidiform mole O01.9 Hydatidiform mole, unspecified ICD-10 ICD Other abnormal product of conception Blighted ovum Mole: NOS carneous fleshy stone 632 Missed abortion Early fetal death before completion of 22 weeks' gestation with retention of dead fetus ICD-10 Other abnormal products of conception O02.0 Blighted ovum and nonhydatidiform mole Mole: carneous, fleshy, intrauterine NOS, Pathological ovum O02.1 Missed abortion Incl.:Early fetal death with retention of dead fetus O02.8 Other specified abnormal products of conception 2013 MSACOG Snow Meeting 29

30 663 Umbilical cord complications. Requires fifth digit; valid digits are in [brackets] under each code. See beginning of section for definitions Prolapse of cord [0,1,3] Cord around neck, with compression[0,1,3] Other and unspecified cord entanglement, with compression [0,1,3] Other and unspecified cord entanglement, without mention of compression [0,1,3] Short cord [0,1,3] Vasa previa [0,1,3] Vascular lesions of cord [0,1,3] Other umbilical cord complications [0,1,3] Unspecified umbilical cord complication [0,1,3] P02 Umbilical cord complications P02.4 Fetus and newborn affected by prolapsed cord P02.5 Fetus and newborn affected by other compression of umbilical cord P02.6 Fetus and newborn affected by other and unspecified conditions of umbilical cord Polyp of female genital tract ICD Polyp of corpus uteri Mucous polyp of cervix Other benign neoplasm of uterus : cervix uteri (adenomatous polyp of cervix) Polyp of Vagina Polyp of labia and vulva 221 Benign neoplasm of other female genital organs (including adenomatous polyp and benign teratoma) ICD-10 N84.0 Polyp of corpus uteri N84.1 Polyp of cervix uteri N84.2 Polyp of vagina N84.3 Polyp of vulva N84.8 Polyp of other parts of female genital tract N84.9 Polyp of female genital tract, unspecified 2013 MSACOG Snow Meeting 30

31 My biggest fear about ICD-10 is: 1. I will have to buy new software. 2. Increased denials. 3. Will need to revise billing sheets. 4. Will need to learn new codes. 5. Other 0% 0% 0% 0% 0% I will have to... Increased deni... Will need to r... Will need to l... Other HELP Sources: Essential guide to Coding in OB/GYN OB/GYN Coding Manual FAQ for OB/GYN CPT-4 and ICD-9 books/online Coding courses 2013 MSACOG Snow Meeting 31

32 Objectives Review Coding Documentation Guidelines ICD-9 and ICD MSACOG Snow Meeting 32