A Practical Introduction to Coding, Managed Care

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A Practical Introduction to Coding, Managed
Care HIPAA
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Components of an Evaluation and Management
Service

• 3 Key Components
• History
• Physical Exam (PE)
• Medical Decision Making
• Time may be used if 50 or more is spent with
  face to face counseling or coordination of care.

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What makes up the History?

• Chief Complaint (CC) the stated purpose or reason
  (usually a quote from the patient - CC Stomach
  pain)
• History of the present illness (HPI) the
  description HPI Recurrent stomach pain, rt.
  lower abdomen, started 2 days ago
• Review of systems (ROS) questions asked to
  identify the signs or symptoms
• Patient/Family/Social History

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Elements of the HPI

• Location/Site (Rt. Lower abdomen)
• Duration/Onset (2 days)
• Timing/Frequency (Recurring)
• Quality/Characteristics (Sharp)
• Severity/Intensity (worsening, pain scale)
• Context/Circumstance (Fell from swing)
• Modifying Factors (took Tylenol)
• Associated Signs/Symptoms (Nausea, Vomiting)

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Elements of ROS

• Constitutional/General
• Eyes
• Ear, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary

• Musculoskeletal
• Skin
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunological

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Distinction between HPI ROS

• If given a description of the problem HPI
• If obtained to further define the scope ROS

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Components of PFSH

• Past History - illness, injuries, surgeries,
  hospitalizations, current meds, allergies,
  immunization status, birth history
• Family History review of health status or cause
  of death of family members, anything which may
  put the patient at risk
• Social History use of drugs, alcohol, age
  appropriate living arrangements, sexual history
  or other relevant social factors

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4 Levels of History

1. Problem focused- CC, Brief HPI (1-3 elements)
2. Expanded problem focused- CC, Brief HPI, 1 ROS
3. Detailed- CC, Extended HPI (4 or more elements or
   3 or more chronic conditions, 2-9 ROS
4. Comprehensive- CC, Extended HPI, 10 ROS, Complete
   PFSH requiring one element from all 3 areas

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Physical Exam (PE)

• Body Areas
• Head, including the face
• Neck
• Chest
• Abdomen
• Genitalia, Groin Buttocks
• Back
• Each Extremity

• Organ Systems
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Muskuloskeletal
• Skin
• Neurological
• Psychiatric
• Hematologic, Lymphatic Immunologic

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Documentation Tips for PE

• All body areas and organ systems must be
  documented separately with positive or negative
  findings
• All abnormal findings must be documented
• Use of a checklist is acceptable
• Only the level of PE that is medically necessary
  should be used in determining the code

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Elements of Medical Decision Making

• Number of possible diagnosis and/or management
  options
• Amount and/or complexity of data ordered or
  reviewed
• Risk of significant complication, morbidity,
  and/or mortality

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Documentation Tips for Medical Decision Making

• Documentation to support medical decision making
  may be found throughout a progress note, in the
  history, exam or assessment and plan
• Documentation needs to provide insight on the
  thought process that leads to the diagnosis

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How does this translate to coding/billing?

• Established Patient E/M
• 99212-Problem focused
• 99213- Expanded problem focused
• 99214- Detailed
• 99215- Comprehensive

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Clinical Example

• A 4-year old boy presents with CC of rash for 2
  days. The mother describes this as a red, bumpy
  rash on his arms and legs that is spreading and
  itchy. No treatment has been tried. He has been
  playing outside in the woods. There has been no
  fever. On physical exam, he is an alert,
  comfortable child with red papules on the lower
  arms and thighs. Your diagnosis is contact
  dermatitis. You prescribe topical steroids and
  OTC antihistamine for itching. You advise to
  return if not improving.

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Clinical Example

• A 16-year old boy presents with complaint of itch
  rash for 2 days after camping in the woods. On
  examination, he is alert with red papules on the
  lower arms and thighs. Diagnosis is mosquito
  bites, and you recommend OTC hydrocortisone and
  antihistamines as needed with discussion on
  prevention.

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Clinical Example

• A 2- year old presents with complaints of
  congestion, sore throat, and runny nose with
  fever. The HP performed are of an expanded
  level. The diagnosis is URI, OTC medications are
  recommended, and you instruct to follow up as
  needed. Before leaving the mother wants to
  discuss current marital problems and the effect
  on the child. A total of 10 minutes was spent on
  the HP for the URI and 20 minutes was spent on
  counseling for the marital issues and their
  effect. You document a total face-to face time of
  30 minutes, with 20 minutes spent on counseling.

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Preventive Medicine

• The code selection is based on the age of the
  patient and if they are new or established.
• Established patient codes 99391-99397
• New Patient codes 99381-99387

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Preventive Medicine

• Does not require a CC or HPI
• Does require a comprehensive age appropriate ROS
  with an updated PFSH. As well as a comprehensive
  assessment or history of age pertinent risk
  factors and a comprehensive PE
• No average times are assigned

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What is Modifier 25?

• When an abnormality or preexisting condition
  requires significant additional work during the
  well visit a problem-oriented visit may be
  reported along with the well visit. A modifier 25
  will be appended to the problem visit.
• Documentation must support the additional work.

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Managed Care
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RBRVS- Resource Based Relative Value Scale

• RBRVS is a tool used to give a dollar value to
  medical and surgical procedures relative to all
  other procedures performed.
• Medicare and commercial payors use RBRVS to
  reimburse providers
• Reimbursement is updated yearly by the federal
  government and is calculated according to
  geographic location

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!!_at_2??/!!

• 2008 Non Facility Pricing Amount ((Work RVU
  Budget Neutrality Adjustor(0.8806))(round product
  to two decimal places) Work GPCI)
  (Transitioned Non Facility PE RVU PE GPCI)
  (MP RVU MP GPCI0) Conversion Factor

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Why use RBRVS?

• It allows payors to have a consistent methodology
  for practitioner reimbursement
• Thankfully you will never have to calculate RBRVS!

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How do payors use RBRVS?

• Payors will use a particular years RBRVS as a
  base fee schedule and then reimburse the provider
  at a multiple of the dollar amount for each CPT
  code (120 of 2008 RBRVS).

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Commercial Payors

• Fully Insured plans- Overseen by state Insurance
  Commissioner. Must abide by state mandated
  benefits. Insurance company is administrator and
  payor.
• Self Insured Plans- Fall under Department of
  Labor. Can set their own benefit structure.
  Insurance company is administrator and employer
  group is payor.

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Interesting Payor Facts

• You are not paid your total charge amount.
• Each payor has a contract with their negotiated
  rates for payment.
• Every service is not always paid at 100 of the
  negotiated rate.
• Some services are not paid at all!!

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Best advice to receive maximum reimbursement

• Document

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HIPAA
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What does HIPAA do?

• Improves efficiency in healthcare delivery by
  standardizing electronic data interchange and
  streamlining transactions
• Protects confidentiality and security of personal
  health data through setting and enforcing
  standards

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No, Really. What does HIPAA do?

• HIPAA addresses a number of standardization
  protocols in healthcare
• Health Insurance Portability
• Administrative Simplification
• Fraud and Abuse
• Medical Savings Accounts
• Access to Long Term Care
• and Coverage

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What do you need to know?
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The Privacy Rule

• Affords consumers protection for privacy of
  medical records and health information
• Use common sense as your safeguard.

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TPO- Treatment, Payment, Operations

• Treatment- Anything regarding the treatment for
  the patient
• Payment- Anything in order to receive payment
  from the patients insurance
• Operations- Anything regarding the daily
  operations to care for the patient.

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Notice of Privacy Practices

• A notice of privacy practices (NPP) informs
  patients about their rights surrounding the
  protection of their protected health information
  (PHI).
• Must be displayed visibly in a facility
• Must be available to all patients

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Thank you

• Pam DeLancey
• Pediatrics and Adolescent Medicine
• 120 Stonebridge Pkwy
• Suite 410
• Woodstock, Ga. 30189
• pdelancey_at_pampapediatrics.com