Coding for Occupational Health Encounters

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Coding for Occupational Health Encounters

• How to Get the Workload Credit You Deserve
• Angela N. Andersen, CPC
• Lead Coder
• Naval Medical Center Portsmouth
• March 2008

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EM Coding

• Upon completion of this presentation, the
  participant should be able to
• Identify the three key components of EM coding
• Recognize the difference between new and
  established patients as it relates to
  documentation and coding.
• More accurately document and select the
  appropriate EM code for the services rendered.

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Contents

• What are EM Codes?
• Why Code?
• How do Codes equate to Workload Credit?
• Why is Documentation important?
• What documentation should be included on every
  encounter?
• Determining the correct EM code
• Time as the determining factor for EM code
  selection
• Preventive Medicine EM code requirements

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What are EM Codes?

• The Evaluation Management (EM) codes are a
  sub-set of the CPT codes.
• Can be used by all privileged providers
• Describes
• Complexity of care provided to a patient for
  non-procedural visits.
• The place of service (inpatient or outpatient)
• The type of service (new vs. est., consult,
  preventive, ER, critical care, etc)

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Why Code?

• Why is it important to code in the military?
• REIMBURSEMENT
• Third Party Payers/Inter-agencies
• Prospective Payment System (PPS)
• FITREP input
• Over coding Fraud
• Under coding Lost RVUs/Revenue

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Coding Workload Credit

• A Relative Value Unit (RVU) is assigned to most
  of the CPT codes, including the EM codes.
• The more complex the service, the higher the RVU
  value assigned
• New Patient RVUs gt Established Patient RVUs
• Consult RVUs gt New patient RVUs
• Prev Med RVUs gt Established patient RVUs
• Under the PPS, RVU average 72.00

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What do Coders look for?

• Every patient encounter should be legible and
  include
• Date of Encounter
• Reason for the visit (chief complaint)
• Appropriate history of present illness
• An exam when necessary or appropriate i.e. a new
  patient (consistency and problem pertinent)
• Review of lab, xray, other ancillary services
  when appropriate
• Assessment
• Plan of care/Treatment options
• Provider signature
• Taken Care of or required fields in AHLTA
  (CHCSII)
• Remember It is the Content, not the volume, of
  documentation that determines your EM code!

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Determining the Correct EM Code

• There are three key components to consider when
  selecting the appropriate EM
• History
• Exam
• Medical Decision Making (MDM)
• All three components must be documented for a new
  patient (new to clinic or not seen within the
  past three years). Indicate in CC if patient is
  new.
• Only two of the three components must be
  documented for established patients (seen within
  the past three years).
• EM selection should never be based on the
  allotted time on the appointment schedule!

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Why is Documentation Important?

• The documentation must support the EM code you
  select.
• Your documentation must support the medical
  necessity of the services provided. The first
  step is to clearly document the reason for every
  visit the chief complaint.
• The use of Follow-up is insufficient
  documentation as it does not indicate medical
  necessity. It is acceptable to document
  Follow-up for _____.
• Remember The coding rule of thumb is If it
  isnt documented, it wasnt done!

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Determining the Correct EM Code

• To determine the correct level EM code, consider
  the complexity of your patients condition and
  your medical decision making, then support that
  level of complexity with your documentation of
  history and/or exam.
• Remember For a new clinic patient, initial
  consult, initial inpatient visit or ED encounter,
  you must document all three key
  componentshistory, exam and your medical
  decision making.

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MDM Component

• Medical Decision Making (MDM) refers to the
  complexity of determining a diagnosis and/or the
  selection of a treatment option. It is measured
  by documentation of the following
• Number of diagnoses and/or management options
  that must be considered.
• Amount and/or complexity of data to be reviewed.
• Risk of complications, morbidity and/or
  mortality, and co-morbidities.
• The four types of MDM include Straightforward,
  Low Complexity, Moderate Complexity, and High
  Complexity.
• To assist in determining your level of MDM see
  Attachment A

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History Component

• Documentation of History includes
• Chief Complaint
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past, Family and or/Social History (PFSH)
• The extent of history is dependent on clinical
  judgment and the nature of the presenting
  problem.
• The four types of History include Problem
  focused, Expanded Problem focused, Detailed and
  Comprehensive.

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Determine your Documented Level of History

• Mark the entry in the farthest right column to
  describe your HPI, ROS and PFSH. If one column
  contains 3 marks, the type of history is
  indicated at the bottom. If no column has 3
  marks, the column marked farthest to the left
  identifies the type of history.

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Exam Component

• The following Body Areas and Organ Systems are
  recognized in EM documentation
• Body Areas Organ Systems
• Head/Face Constitutional (vitals,etc)
• Neck Eyes
• Chest/breasts/axillae Ears/nose/mouth/throat
• Abdomen Cardiovascular
• Genitalia/groin/buttocks Respiratory
• Back, including spine Gastrointestinal
• Each extremity Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric Hematologic/lymphatic/
  immunologic
• The four types of Exam include Problem focused,
  Expanded Problem focused, Detailed and
  Comprehensive.
• To assist in determining your level of PE see
  Attachment B

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Final EM Selection

• Determining your Level of Service
• PF Problem Focused SF Straightforward
• EPF Expanded Prob Focused L Low Complexity
• D Detailed M Moderate Complexity
• C Comprehensive H High Complexity

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Determining the Correct EM Code

• Consider the patient who has multiple chronic
  problems requiring prescription drug management.
  This patient would be considered a moderately
  complex patient and with the proper documentation
  of the other two components (Hx and Exam) this
  can be coded as a level four EM visit.
• For a new patient/consult level IV visit (99204,
  99244) Need to document a comprehensive history
  and comprehensive exam.
• For an established patient level IV (99214)
  Need to document a detailed history and/or
  detailed exam.

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Time as a Key Component

• If more than 50 of your time with a patient is
  spent counseling or coordinating care, time can
  be used in selecting the EM level.
• Document counseling topics/coordination of care.
• Prognosis, differential diagnoses, risks/benefits
  of treatment, compliance, discussion with another
  healthcare provider
• Document providers total face-to-face time plus
  time spent counseling or coordinating care for
  patient.
• Example 45 min visit/30min counseling
• Do not include resident/support staff time with
  patient.

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Preventive Medicine

• New Patient
• 99381-99387
• Established Patient
• 99391-99397
• Counseling
• 99401-99404 Individual
• 99411-99412 Group
• 99381-99397 are based on the age of the patient
• 99401-99412 are based on time spent counseling.

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Preventive Medicine

• 99381-99397
• This code series includes counseling /
  anticipatory guidance / risk factor reduction
  interventions which are provided at the time of
  the initial or periodic comprehensive preventive
  medicine examination. Comprehensive in this code
  series is NOT synonymous with the comprehensive
  examination required in 99201-99350.
• 99401-99412
• This code series cannot be coded on the same day
  as a preventive medicine examination visit. To
  code for these services the patient cannot have
  any symptoms or an established illness.

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Capture More Workload

• Smoking Cessation Counseling
• G0375 3-10 minutes
• G0376 10 minutes
• Digital Rectal Exam for Prostate Cancer Screening
• G0102
• Visual Acuity Exam (Snellen Chart)
• 99173
• Needle Sticks!!
• 96150 when the OH nurse sees a patient due to
  a needle stick he/she can code this encounter as
  99499 E/M and 96150 CPT with the applicable ICD-9
  primary for the wound and a secondary ICD-9 code
  of the External cause.

NEW 2008 E/M Codes for Smoking Cessation 99406
and 99407 to replace the procedural codes G0375
and G0376.
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Common Coding Errors in OH

• V68.0x Issuance of Certificate
• This is a PRIMARY only ICD-9 code and should not
  be used in the secondary diagnosis slot.
• V70.x General Medical Exam
• This is a PRIMARY only ICD-9 code and should not
  be used in the secondary diagnosis slot.
• Routine visits that turn into an Acute visit for
  a finding upon exam.
• Providers must document all applicable
  information required for the preventive service.
• If an acute finding is discovered and managed
  during the same encounter the provider should
  Expand his/her documentation pertinent to this
  finding and code an ADDITIONAL separate E/M code
  for the acute finding.

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Common Coding Errors in OH

• Coding in AHLTA
• You MUST verify the E/M code chosen by AHLTA in
  the Disposition screen.
• It has been a common place error that providers
  are being given non-count E/M code 99429 for
  preventive visits OR Preventive E/M 99381-99397
  for acute care visits.
• New patient vs. Established patient
• While the front desk books these appointments
  providers should always double check the patients
  status in AHLTA.
• New patients are worth higher RVUs and you will
  lose out if you let the system default to an
  established patient E/M.
• Preventive Medicine and Acute Care Same Day
• AHLTA will not automatically code your encounter
  with a Preventive E/M (99381-99397) and an Acute
  E/M (99201-99215).
• The provider must manually code the additional
  E/M code in the disposition screen based on
  his/her documentation. Be sure to add a 25
  modifier to your Acute E/M.

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E/M RVUS

• 99201 0.45
• 99202 0.88
• 99203 1.34
• 99204 2.30
• 99205 3.00
• 99211 0.17
• 99212 0.45
• 99213 0.92
• 99214 1.42
• 99215 2.00
• 99384 1.53
• 99385 1.53
• 99386 1.88

• 99387 2.06
• 99394 1.36
• 99395 1.36
• 99396 1.53
• 99397 1.71
• 99358 2.10
• 99359 1.00
• 99401 0.48
• 99402 0.98
• 99403 1.46
• 99404 1.95
• 99411 0.15
• 99412 0.25

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PROCEDURAL RVUS

• 94010 0.17
• 99000 0.05
• 36415 0.06
• 99173 0.00
• 96150 0.50
• 96151 0.48

• 93000 0.17
• 93010 0.17
• G0375 0.24
• G0376 0.48
• G0102 0.17

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Summary

• Are you going to let RVUs slip away?
• By incorporating some of the information
  discussed today into your notes, you can honestly
  increase your RVUs and reimbursement.
• Keep in mind that AHLTA does not code for you
  completely you must always check your codes
  before finalizing your note.
• Templates are your best tool to maximize your
  coding in AHLTA.

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Questions?

• Contact Information
• Angela N. Andersen, CPC
• Office 757.953.1241
• Cell 757.333.2066
• Angela.Andersen_at_med.navy.mil