Developmental Screening: Billing and Coding

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Developmental ScreeningBilling and Coding

• Michelle M. Macias, MD
• D-PIP Training Workshop
• June 16, 2006

I have no relevant financial relationships with
the manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed
in this CME activity.
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Importance of Accurate Coding

• Improved Information Processing
• Accurate diagnostic coding requires analyzing all
  provided information (subjective and objective)
• Decreased Liability
• Documentation
• Medico-legal
• Compliance
• Increased Reimbursement
• One minute of extra work can result in an
  increased code level

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Diagnostic Codes

• International Classification of Diseases-Tenth
  Revision, Clinical Modification (ICD-10-CM)
• Arranges diseases and injuries into groups
  according to established criteria
• Numeric
• Revised q 10 years by WHO, annual updates by
  Health Care Financing Administration (HCFA)
• U.S. still using ICD-9 codes, gradually
  implementing ICD-10

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ICD-9 Codes

• Code to the highest degree of specificity
• Code to the highest degree of certainty for the
  encounter such as symptoms, signs, abnormal test
  results
• Probable, suspected, questionable, or rule out
  should not be coded
• List the ICD-9/10 code that is identified as the
  main reason for the service first, then list
  co-existing conditions
• Chronic disease treated on an ongoing basis may
  be coded
• Do not code for conditions previously tx that no
  longer exist

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Developmental Coding Examples

• 783.42 Delayed milestones
• 728.85 Hypertonia
• 315.31 Language disorder, developmental
• 315.9 Learning disorder, NOS
• 348.3 Static encephalopathy

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Current Procedural Terminology (CPT)

• Published by the AMA
• Listing of the codes and descriptions for
  procedures, services and supplies
• Used to bill insurance carriers

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CPT Coding5 Basic Principles of Use

• Practitioner should select diagnosis and
  procedure codes
• Document patients services to support codes
  (compliance)
• Use separate codes for different encounters
• Learn to use modifiers, testing and add-on codes
• Design a superbill/computerized routing sheet

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RVU Review

• Resource Based Relative Value Scale (RBRVS)
• Relative Value Units (RVUs) The Coin of the
  Realm
• A numerical value (relative reimbursement)
  assigned to a CPT code
• Calculated on
• Amount of physician work
• Practice expenses
• Malpractice cost
• Service location (office vs. hospital)

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RVU Components of Physician Work

• Pre-, intra-, post- service work
• Time to perform the service
• Technical skill and physical effort
• Mental skill and judgment
• Psychological stress associated with iatrogenic
  risk

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RVUs ? Cash

• RVUs are assigned by the Relative Value Scale
  Update Committee (RUC)
• Each 3rd party payer that uses RVus in payment
  calculations applies its own conversion factor
  (CF)
• The CF is multiplied by the RVU to determine that
  payors payment

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TABLE 2CPT Codes for Developmental Screening
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Developmental Screening

• 96110 Developmental screening
• Limited developmental testing, with
  interpretation and report
• Expectation is that the screening tool will be
  completed by a non-physician staff member and
  reviewed by the physician
• No physician work is included in the RVU
• Reported in addition to E/M services provided on
  same date, with modifier (-25)
• Report for each screen administered
• Medicaid may not pay separately for developmental
  screening when provided as part of Early and
  Periodic Screening, Diagnostic, and Treatment
  services (EPSDT)

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Developmental Testing

• 96111 Extended developmental testing/evaluation
• Used for extended developmental testing typically
  provided by the medical provider
• Includes the interpretation and report
• Based on 1 hr of physician work
• Reported in addition to E/M services provided on
  same date, with modifier

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Evaluation and Management (E/M) Codes

• Bill based on level of complexity- 3 major
  components
• History
• Physical Exam
• Medical Decision Making (MDM)
• Bill based on time
• Only if counseling and coordination of care gt 50
  of visit

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Complexity Billing History
Type HPI ROS PFSH
Problem Focused Brief (1-3) N/A N/A
Expanded Problem Focused Brief (1-3) Brief (1)
Detailed Extended (4) Extended (2-9) Pertinent (1)
Comprehensive Extended (4) Complete (10) Complete (2/3 or 3/3)
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Examination

• Problem Focused
• Limited to affected body area or organ system
• 1 body area/organ system
• Expanded Problem Focused
• Affected body are or organ system and other
  symptomatic or related organ system
• 2-4 body areas/organ systems
• Detailed
• Extended exam of affected body area(s) and other
  symptomatic or related organ systems
• 5-7 body areas /organ systems
• Comprehensive
• Complete single system specialty exam or
• Complete multi-system exam
• 8 or more body areas/organ systems

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Medical Decision Making

• Number of possible diagnoses and/or management
  options
• Amount and/or complexity of medical records,
  diagnostic tests, and/or other information that
  must be reviewed
• Risk of complications, morbidity and/or
  mortality, associated with the patients
  presenting problem. Includes need for diagnostic
  procedures and management options

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Medical Decision Making
Decision Making Number of Diagnoses Amount of Data Risk of Complication
Straight forward Minimal Min. or None Minimal
Low Complexity Limited Limited Low
Moderate Complexity Multiple Moderate Moderate
High Complexity Extensive Extensive High
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Time Reporting CPT Counseling Rule

• Use when the time spent in counseling and
  coordination of care gt 50 of the EM visit
• The 3 key components of history, PE, MDM may be
  ignored
• Only time is used to select the level of care
• A summary of the counseling discussion should
  be included with the note
• Does not include screening time
• Reported separately, with modifier (-25)

Believe me, this is the best way to get paid for
visits focused on developmental and behavioral
problems
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Preventive Medicine Services

• E/M services performed in the absence of a
  significant problem/abnormality
• Extent and focus depends on the patients age
• Included counseling/anticipatory guidance/risk
  factor reduction

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Preventive Medicine Services

• New Patient
• Initial E/M of a new patient including an age
  and gender appropriate history, examination
  identification of risk factors, ordering of
  appropriate tests, and counseling
• RVU/2003 Medicare
• 99381 Agelt 1 year 2.75/101.16
• 99382 Ages 1-4 years 2.96/108.89
• Established Patient
• Periodic reevaluation and management requiring
  an age and gender appropriate history,
  examination identification of risk factors,
  ordering of studies, and counseling
• RVU/2003 Medicare
• 99391 Agelt 1 year 2.08/76.51
• 99392 Ages 1-4 years 2.33/85.71

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Office Visits-New Patient
Codes 99201 99202 99203 99204 99205
History Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehensive
Exam Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehensive
Decision Making Straight Forward Straight Forward Low Complex Moderate Complex High Complex
Time FF 10 20 30 45 60
Key 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3
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Office Visits-Established Patient
Codes 99211 99212 99213 99214 99215
History Not Required Problem Focused Expanded Problem Focused Detailed Comprehensive
Exam Not Required Problem Focused Expanded Problem Focused Detailed Comprehensive
Decision Making Not Required Straight Forward Low Complex Mod Complex High Complex
Time FF 5 10 15 25 40
Key 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3
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Consultations

• Consultation is a service provided by a physician
  whose opinion or advice is requested by another
  physician or other appropriate source
• Consultant may initiate diagnostic and/or
  therapeutic services
• Consultant must document
• -Request for consultation (written or verbal)
• -Need for consultation
• -Opinion and services ordered and performed
• -Communication by written report back to the
  referring source

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Office Consultation/ New or Est
Code 99241 99242 99243 99244 99245
History Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehen.
Exam Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehen.
Decision Making Straight-forward Straight-forward Low Complex Mod Complex High Complex
Time FF 15 30 40 60 80
Key 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3
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Prolonged Services(99354-99359)

• Code series defining prolonged services by
• Site of service
• Direct or without direct patient contact
• Time
• Reported in addition to other physician services,
  including E/M services at any level
• Total time for a given date, even if the time is
  not continuous
• Time must be of 30 minutes or more

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Prolonged Services
Direct Patient Care Outpatient
Face to Face 99354 first 30-74 min
Face to Face 99355 each add 30 min gt75
Before or after Face to Face 99358 first 30-74 min of non-face to face
Before or after Face to Face 99359 each add 30 min gt75 min
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Modifiers

• Services altered by specific circumstance
• Tells insurer this visit is different
• -21 Prolonged E/M Service
• -25 Significant separately identifiable E/M
• Service by the same physician on the same day
• Used to report developmental screening with E/M
  code
• -32 Mandated Services
• -52 Reduced Services