Richard Lander, MD, FAAP CPT CODING FOR YOUR MEDICAL HOME

Transcription

1 Richard Lander, MD, FAAP CPT CODING FOR YOUR MEDICAL HOME

2 Section on Administration and Practice Management (SOAPM) Home to pediatricians interested or involved with the management or administration of pediatric practices. Provides both basic and cutting edge administration and practice management information to its members. Benefits: SOAPM LISTSERV discussions SOAPM s newsletter soapmnews (bi-annual) Pediatric Practice Managers Association SOAPM NCE programs Open to all FAAPs, Resident Fellows, and eligible Affiliate Members with an interest or active in practice management. Applications for Fellows and Affiliate Members are available on the AAP Member Center at:

3 CPT FOR THE MEDICAL HOME Whose home is it?

4 MEDICAL HOME Julian s mom brings him complaining that he is tugging on his right ear. After an examination you diagnose him with an acute otitis media and discuss treatment Is this a medical home?

5 MEDICAL HOME Erica admits to you she has had an alcohol problem for the last 6 months. You help her find the appropriate care Is this a medical home?

6 MEDICAL HOME During your lunch break you take a phone call from the pediatric gastroenterologist about your mutual patient Jeffrey. The GI doctor wants him to see an ENT and you agree to take care of this Is this a medical home?

7 MEDICAL HOME The answer to all these questions is a resounding YES. The pediatrician s office has always been a medical home. We invented it years ago!

8 CPT FOR THE MEDICAL HOME The AAP gave birth to the medical home as Pediatricians we have coordinated care for our patients So what is Patient Centered Medical Home? it is the same thing but now with Internists and Family Practitioners embracing the concept, it has a fancy name

9 CPT FOR THE MEDICAL HOME PATIENT CENTERED MEDICAL HOME doing more for your patients than you did before to keep them in you home face-to-face visits evaluation and treatment of ADHD treatment of warts minor surgery non-face-to-face visits care coordination

10 CPT FOR THE MEDICAL HOME So how do I code for what I do in the PCMH?

11 What is coding and why is it important to me? Coding is how you will make your living It tells the insurers and auditors what the patient s problems were and what you did for them It s how you get paid

12 Increase Reimbursement and Decrease Liability Through Physician Knowledge and Use of Coding Increase revenues by increasing productivity without working harder!

13 CPT FOR THE MEDICAL HOME Basic CPT coding remains the same Learn the CPT codes as you coordinate care for your patients Medical Team coding Physician and Non-Physician Prolonged services coding Category II codes

14 Well visit codes Very simple Only need to know if patient is old or new and the age New patient one not seen by you or the practice in 3 years

15 Well visit Codes New Patients under 1 year years years years years

16 Well Visit Codes Established Patients under 1 year years years years years

17 Evaluation and Management Codes Routine sick visits Based on severity of illness and work done If more than 50% of visit is counseling, then time is an element

18 E/M Codes New patient codes require all 3 elements Established patients only require 2 out of 3 elements doesn t require the presence of a physician

19 Office Visits New Patient Codes History Problem Focused Expande d Problem Focused Detailed Compre hensive Compre hensive Exam Problem Focused Expande d Problem Focused Detailed Compre hensive Compre hensive Decision Making Straight forward Straight forward Low complex Moderat e complex High complex Time FF

20 Codes History Require d Element s Exam Require d Element s Not Required Not Required Problem Focused HPI 1-3 ROS N/A PFSH N/A Problem Focused Expande d Problem Focused HPI 1-3 ROS 1 PFSH N/A Expande d Problem Focused 1 Area 2-4 Areas Detailed Compre hensive HPI 4+ ROS 2-9 PFSH 1/3 HPI 4+ ROS 10+ PFSH 2/3 Detailed Compre hensive 5-7 Areas >8 Areas

21 CPT FOR THE MEDICAL HOME Perhaps as a PCMH you will be providing more services to you patients, i.e. procedures or as I like to call them the

22 PROCEDURES INTEGUMENTARY SYSTEM ACNE SURGERY I&D OF ABSCESS COMPLICATED OR MULTIPLE I&D FOREIGH BODY SUBQ I&D OF HEMATOMA OR FLUID COLLECTION

23 PROCEDURES INITIAL TREATMENT FIRST DEGREE BURN- LOCAL TREATMENT DRESSING AND/OR DEBRIDEMENT WITH/WITHOUT ANESTHESIA SMALL TO LARGE DESTRUCTION(ACTINIC) DESTRUCTION WARTS CHEMICAL CAUTERIZATION

24 PROCEDURES CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION THUMB WITH MANIPULATION NOT THUMB CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE WITHOUT MANIPULATION

25 PROCEDURES REMOVAL FB INTRANASAL NEWBORN CIRCUMCISION LYSIS OF PENILE POSTCIRC ADHESIONS FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS

26 PROCEDURES SCREENING VISUAL ACUITY VITAL CAPACITY INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION DEMO OR EVALUATION OF PTUSE OF NEBULIZER OR MDI MANIPULATION OF CHEST WALL

27 WELL AND SICK VISITS 3 y/o Joey comes in for her well visit. She is wheezing and has subcostal retractions What do you do? a. cancel the well visit and treat the asthma b. do both well and sick visits c. send her to the hospital d. check her insurance

28 WELL AND SICK VISITS d. check insurance first If the insurance company will not pay you for both visits you have a decision to make- a. do both visits and lose money b. perform the well visit and send her to the ER c. treat the asthma and have the family reschedule the well visit

29 WELL AND SICK VISITS There is no right answer Personally I think that none of us should choose to lose money because the patient s insurance won t pay for both visits. The patient s have chosen their insurance and they have to learn to live with the affects of their decisions

30 CPT FOR THE MEDICAL HOME Erica has come into the office wheezing. Here are your findings: cc, hpi-5 items, ph, fh, ros-3, physical exam includes 7 systems You give Erica a pulmonary function test and based on that a nebulizer treatment with Xopenx. You then code the visit as 99214, and (if you purchased the Xopenex add j7614

31 CPT FOR THE MEDICAL HOME Let s say that Erica needed a second nebulizer treatment. You would then notate the and repeat it with the modifier 76 after it. This tells the MCO that the same physician, on the same day performed the same procedure on the same patient again.

32 CPT FOR THE MEDICAL HOME Let s change the scenario again. You send Erica home after the first nebulizer treatment. You too go home. Erica gets worse, returns to the office where one of your associates evaluates her and repeats the nebulizer. You now code the visit as 99214, 94640, , a. True b. False

33 CPT FOR THE MEDICAL HOME b. false The repeat should not have the 76 modifier as it wasn t the same doctor. The 77 modifier is for the same patient, the same day, the same procedure repeated but by another doctor. So with the 77 modifier we are okay a. true b. false

34 CPT FOR THE MEDICAL HOME b. false Everything is okay except for the With the extra work provided by the second doctor in the afternoon you could now use and get paid more money!

35 MODIFIERS SOMETHING DIFFERENT WAS DONE -25 SIGNIFICANT, SEPARATELY IDENTIFIABLE E&M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE NOT TO BE USED WHEN A DECISION IS REACHED TO PERFORM SURGERY

36 MODIFIERS -63 PROCEDURE INFANT < 4KG -76 REPEAT PROCEDURE BY SAME PHYSICIAN, SAME PT, SAME DAY -77 REPEAT PROCEDURE BY DIFFERENT PHYSICIAN, SAME PT, SAME DAY

37 MODIFIERS -50 BILATERAL PROCEDURES -51 MULTIPLE PROCEDURES -53 DISCONTINUED PROCEDURE -59 DISTINCT PROCEDURAL SERVICE

38 CPT FOR THE MEDICAL HOME You have spent 70 minutes with Jeffrey and want to be paid for your time. a b c , 99354

39 CPT FOR THE MEDICAL HOME a you lost money (code for 40 min) b why? c , prolonged face-face, minutes office or outpatient setting for each additional 30 minutes after 99354

40 CPT FOR THE MEDICAL HOME IN THE PCMH THERE WILL BE TIMES WHEN THE PATIENT CARE IS NOT FACE-TO-FACE

41 CPT FOR THE MEDICAL HOME PROLONGED SERVICE WITHOUT PATIENT CONTACT may be reported on a different date i.e. record review must relate to service where direct care has or will occur total duration of time on specific date

42 CPT FOR THE MEDICAL HOME PROLONGED SERVICES WITHOUT DIRECT PATIENT CONTACT minutes each additional 30 minutes must be at least an additional 15 minutes

43 CPT FOR THE MEDICAL HOME MEDICAL TEAM CONFERENCE minimum 3 qualified healthcare professionals face-to-face evaluation must have taken place within 60 days time related to record keeping and report generation not reported

44 CPT FOR THE MEDICAL HOME MEDICAL TEAM CONFERENCE, DIRECT CONTACT WITH PATIENT &/or FAMILY minutes+ nonphysician MEDIAL TEAM CONFERENCE, WITHOUT DIRECT CONTACT minutes+ with physician nonphysician

45 CPT FOR THE MEDICAL HOME CARE PLAN OVERSIGHT SERVICES reported separately from the other codes we have discussed services within a 30 day period only one physician may use this for a given period of time-sole or predominant supervisory role does not include low intensity or infrequent supervision

46 CPT FOR THE MEDICAL HOME CARE PLAN OVERSIGHT physician supervision of a patient under care of home health agency, requiring physician development &/or revision of plans, patient status, etc minutes per month minutes or more

47 CPT FOR THE MEDICAL HOME CARE PLAN OVERSIGHT supervision of hospice patient minutes minutes or more supervision of nursing facility patient minutes minutes or more

48 CPT FOR THE MEDICAL HOME COUNSELING RISK FACTOR REDUCTION no specific illness present diet and exercise substance abuse sexual practices injury prevention

49 CPT FOR THE MEDICAL HOME PREVENTIVE MEDICINE, INDIVIDUAL COUNSELING minutes minutes minutes minutes

50 CPT FOR THE MEDICAL HOME BEHAVIORAL CHANGE INTERVENTIONS for behavior that is an illnesss to change harmful behavior that has not yet become an illness

51 CPT FOR THE MEDICAL HOME tobacco cessation 3-10 minutes greater than 10 minutes alcohol &/or substance abuse structured screening and intervention minutes greater than 30 minutes

52 CPT FOR THE MEDICAL HOME GROUP COUNSELING for patients with symptoms or established illness preventive counseling or risk factor reduction

53 CPT FOR THE MEDICAL HOME NON-FACE-TO-FACE Telephone physician to patient cannot use if seen in next 24 hours cannot use if problem previously addressed in last 7 days Online and must be permanently stored once in 7 days for a particular service cannot be used if previous e&m service

54 CPT FOR THE MEDICAL HOME TELEPHONE minutes minutes minutes ONLINE 99444

55 CPT FOR THE MEDICAL HOME Since you want to have a medical home you also want to have a strong, and busy medical home To help do this you will need to be able to recall your patients for vaccines and well visits

56 RECALL OR NOT TO RECALL ADVANTAGES BRING PATIENTS INTO THE OFFICE Opportunity for annual examination CPT Opportunity to discuss health risks CPT Behavioral change interventions CPT Opportunity to vaccinate

57 RECALL OR NOT TO RECALL I m so busy now how can I see more patients and why should I? the why is easy,-it is to protect your patients against the vaccine preventable diseases

58 RECALL OR NOT TO RECALL Monetary advantages of bringing the patient in for a well examination if you added one additional well visit per day to your schedule and were paid $ for that visit you would increase your revenue for a 50 week year by$25, if you used any screening tools (PHQ9) and or the CPT codes (counseling/prevention) you could add an additional $

59 ADDITIONAL REVENUE PROFIT ON THE VACCINE ITSELF 10-25% OVER ACQUISTION COST PEDIATRICIANS SPEND $100,000/doc profit $10-25,000

60 ADDITIONAL REVENUE VACCINE ADMINISTRATION FEES PAID BY ALL MCO INCLUDING MEDICAID $10-30 per vaccine 2500 patients per doc if you immunized 50% of your practice for influenza the fees generated would be $12,500-$37,500 for administration only this alone would pay for 1 fulltime staff

61 CPT FOR THE MEDICAL HOME WHAT TO DO IF MANAGED CARE ORGANIZATIONS WON T ACCEPT THE CPT CODES? renegotiate your contracts demonstrates cost savings with the medical home demonstrate improved patient outcomes with the medical home

62 CPT FOR THE MEDICAL HOME How else can you increase what you get paid for what you do? NCQA Certification P4P Programs

63 CPT FOR THE MEDICAL HOME What are category II CPT codes? There were developed to simplify reporting of performance measures. These are directly related to Pay-for- Performance programs which if you qualify for them, will put more money in your pocket for the same amount of work done.

64 CPT CATEGORY II These codes describe the performance of a clinical service. The regular CPT codes are also reported. The codes are grouped within categories based on, history, physical findings, assessment, plan, etc.

65 CPT CATEGORY II The categories are: Composite measures 0001F-0015F Patient management 0500F-0575F Patient history 1000F-1220F Physical exam 2000F-2050F Diagnostic screening 3006F-3573F Therapeutic, preventive, other interventions 4000F-4306F

66 CPT CATEGORY II Follow-up, other outcomes 5005F-5100F Patient safety 6005F-6045F Structural measures 7010F-7025F

67 CPT CATEGORY II There are four different modifiers 1P-exclusion due to medical reasons 2P-exclusion due to patient choice 3P-exclusion due to system reason(not covered, resources not available) 8P-not performed, not otherwise specified

68 CPT CATEGORY II An example courtesy of the AAP: A patient presents as a follow-up for moderate, persistent asthma on albuterol and inhaled steroids. His history, physical exam and medical decision which includes continuing his meds contribute to the CPT code of with the ICD-9 of

69 CPT CATEGORY II You also report the following with the F-persistent asthma 1038F-persistent asthma 4015F-persistent asthma, long-term control medication prescribed Since you participate in a P4P program this documentation will support the extra money you now receive

70 CPT FOR THE MEDICAL HOME Learn CPT and ICD-9 coding Document your notes appropriately Capture all your services on the superbill Review your EOBs to update your fee schedules Negotiate good contracts with the MCOsdon t be afraid to drop your poor payors MAKE MONEY caring for your patients

71 The Truth: No Margin-No Mission Physicians choose the best practices for quality care for children Then must use the coding and contracting systems to fund the services Those established services (such as vaccine delivery) that are undervalued may end

72 A DAY IN THE LIFE Let s call it a day-go home early and relax