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 97205 P 503-943-2500 F 503-943-2501 www.ochin.org
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
EVALUATION AND MANAGEMENT
New Patient VS. Established Patient 99201-99205 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.
Established Patient Visit 99211-99215 - Definition of Established Patient- A patient who has been seen within the last three years. Common Denial- patient no longer qualifies as New patient.
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.
HISTORY COMPONENT- HPI History of present illness ROS Review of systems PFSH Past Family Social History EXAM COMPONENT- Body Areas Organ Systems
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.
E &M Cheat Sheet
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.
BREAKDOWN OF TIME Face-To-Face Time 99201 10 minutes 99211 5 minutes 99202 20 minutes 99212 10 minutes 99203 30 minutes 99213 15 minutes 99204 45 minutes 99214 25 minutes 99205 60 minutes 99215 40 minutes
Preventative Care New Patient AGE Established Patient 99381 under 1 year old 99391 99382 1-4 years 99392 99383 5-11 years 99393 99384 12-17 years 99394 99385 18-39 99395 99396 40-64 99396 99397 65 + 99397
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
DIAGNOSIS CODES MMIS- Medicaid Management Information System ICD-9 http://www.oregon.gov/ohppr/hsc/docs/oc t10icd_9.pdf CPT http://www.oregon.gov/ohppr/hsc/docs/oc t10cpt.pdf
VFC VACCINES FOR CHILDREN
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
OREGON CONTRACEPTIVE CARE CCare
The Purpose of CCare To improve family well-being Reduce unintended pregnancies Increase access to health care Provide contraceptives & Family planning services
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
CCare Billing T015- FP Supply codes Example of a CCare claim
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
MODIFIER -25
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: 99213-25 office visit 99396 preventive care
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?
QUESTIONS?? THANK YOU FOR YOUR TIME! Carley Spangler, CPC 707 SW Washington Street Suite 1200 Portland OR 97205 Phone 503.943.2500 Fax: 503.943.2501 Email: info@ochin.org www.ochin.org