Preventive Services Improvement Initiative

1

• Coding 101

Taken from Beginning Coding, Intermediate
Coding, and I Hate Coding by Dianne Demers
2
Ice Breaker
3
Coding and Documentation

• Objectives
• The Participant will be able to
• Define CPT, ICD 9, and DSM 4 Coding
• Explain the reasons why appropriate coding and
  documentation is so important in SBHC settings.
• Demonstrate correct use of CPT and ICD 9 codes

4
Coding Background and Terminology
5
Coding Definition

• Coding is an alphanumeric system used to
  translate medical procedures and services into
  data

6
Types of Coding

• Current Procedural Terminology (CPT)
• International Classification of Diseases (ICD-9
  Clinical Modification - CM)
• Diagnostic and Statistical Manual of Mental
  Disorders (DSM IV-TR)

7

• Coding Is Not The Same As Billing

8
Coding is Medicare Drive

• Pediatrics was not considered in original coding
  guidelines, so some of the things we do in SBHCs
  may not fit well

9
SBHC Coding

• There is no difference between coding in a SBHC
  and any other setting the coding assumptions
  are the same.
• You provide the same level of care regardless of
  the location.

10
Why Code Correctly?

• Reimbursement depends on it.
• Codes describe the services you provide
• Codes justify these services
• Services not documented never happened
• PS Never code for the purpose of getting more
  money

11
The Coding Process has 2 Parts

• 1. What you did CPT
• 2. Why you did it ICD-9 or DSM-4 TR
• YOU MUST ALWAYS USE BOTH
• a what and a why
• (NO EXCEPTIONS)

12
When a provider is under-coding they tell the
wrong story

• This wrong story is
• SBHC Providers are seeing very few patients with
  multiple problems.
• SBHC Providers should see more patients since
  they are not seeing complicated patients.
• The SBHC should decrease the number of physicians
  and add more mid-level providers.

13
There Are Two Coding Guidelines - 1995 1997

• Both 1995 and 1997 guidelines are approved for
  use by CMS
• Agencies may specify use of 1995 or 1997
  guidelines
• 1997 guidelines are more specific than 1995 in
  the examination portion (they are more computer
  friendly)
• New guidelines have been proposed, but have not
  yet been accepted

14
Coding Guidelines 1995 vs. 1997

• This lecture is based on the 1995 guidelines
  because they are 15 pages long vs. 57 pages of
  the 1997 version.
• www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf

15
Fraud

• Intentional deception or misrepresentation
• Deliberately billing for services not performed
• Unbundling of services
• Intentionally submitting duplicate claims

16
Abuse

• Improper billing practices
• Billing for non-covered services
• Misusing codes on a claim form

17
Errors

• Accept it, you will make them.
• Your best defense is having a plan for your
  coding and being able to explain it.

18

• Coding Does Not Equal Good Medicine

Coding

19
But - Coding is Good Documentation
20
CPT Codes document

• Level of Service
• Procedures Provided

21
Examples of CPT codes
Preventive Health 99391 99392 99393 99394 99395 9
9397 99397

• Evaluation Management
• 99211
• 99212
• 99213
• 99214
• 99215

22
ICD-9 Codes document

• The reason behind the visit
• (They must support the CPT codes)

23
General Coding Principles

• Coding gets you paid for your services
• Coding can be used to justify the need for
  services to your funders

24
Coding with ICD-9

• ICD-9 codes have 3, 4 or 5 digits
• The greater the number of digits, the higher the
  specificity
• Use a 5-digit code when it exists
• Use a 4-digit code only if there is no 5-digit
  code with the same category
• Use a 3-digit code only if there is no 4-digit
  code within the same category
• PS Omitting the required 4th or 5th digit will
  result in the denial of a claim. Do not add any
  additional digits, even zero

25
ICD-9-CM Codes

• Range from 001.0 to V82.9
• They identify
• Diagnoses
• Symptoms
• Conditions
• Problems
• Complaints
• Other reason for the procedure, service, or
  supply provided

26
ICD-9-CM Codes

• Three volumes
• Volume 1 Tabular List of Diseases
• Notes all exclusive terms and 5th-digit
  instructions
• Volume 2 Alphabetic Index of Diseases
• Does not contain detail Do Not code from this
  volume
• Volume 3 Procedures
• Used almost exclusively for hospital services
• PS (All 3 Volumes are generally found in one
  binding)

27
V Codes

• For circumstances other than disease or injury
• Three categories
• Problem Could affect overall health status, but
  is not a current illness or injury
• Ex. V14.2 Personal history of allergy to
  sulfonamines
• Service Circumstances other than illness or
  injury
• Ex. V68.1 Issue of a repeat prescription
• Factual Certain facts that do not fall into the
  problem or service categories

28
V Codes

• Can be used as a
• Solo Code
• Principal code
• Secondary code
• May represent check-ups, screenings,
  administrative requests, prescription refills

29
Rules for Coding Outpatient Visits
30
Determine Type of Office Visit

• Evaluation and Management
• New Patients vs. Established Patients
• Preventive Health Visits
• New Patients vs. Established Patients
• Counseling Visits
• Medical Visit talker only
• Mental Health Visits
• New Patients vs. Established Patients

31
Determine Medical Necessity

• Services are reasonable and necessary for the
  diagnosis and treatment of illness or injury.
• All payors define necessity differently
• Clinical rationale must be documented through
  coding.
• You cannot write more, to get paid more.

32
Determine Chief Complaint

• The reason for the patients visit
• S of a SOAP note
• Codes used must relate to chief complaint or they
  are invalid
• And, the chief complaint must be documented in
  the chart

33
Evaluation/Management (E / M) Services

• Used for acute care visits
• Five levels of service
• Seven components within the levels
• Key components history, exam and medical
  decision making
• Contributory components counseling,
  coordination of care, nature of presenting
  problem, and time

34
Evaluation/Management (E / M) Services

• Beginning information about coding deals with
  the three key components
• History
• Examination
• Medical Decision Making

35
Evaluation/Management (E / M) Services

• There are 5 Levels of service
• Minimal
• Self-Limited or Minor
• Low Severity
• Moderate Severity
• High Severity

36
Most Problems Are Not Level 1

• Level 1 is
• A problem that may not require the presence of
  the physician, but service is provided under the
  physicians supervision.
• This is a non-provider visit
• Documentation is required but flow sheet is
  sufficient
• If this level is used, it states that the
  expertise of a medical provider is not necessary

37
CPT Codes Used for E/M Visits

• New Patients
• Level 1 99201
• Level 2 99202
• Level 3 99203
• Level 4 99204
• Level 5 99205

• Established Patients
• 99211
• 99212
• 99213
• 99214
• 99215

38
Coding Steps
39
Coding Steps

• First Step - Determine if your patient is
• A New Patient
• or
• An Established Patient

40
Definition of a new patient

• It is the patients first visit to the provider
• The patient has not received any professional
  services from the provider or another provider of
  the same specialty who belongs to the same group
  practice, within the past three years.
• PS Any time a patient is seen in an Emergency
  Room they are considered a new patient

41
If your patient does not meet the definition of a
New Patient, then they are an Established Patient
42
Coding Steps

• Second Step - determine the level of service for
  the visit,
• To do this you need to determine the level of
  service for each key component separately
• There are 3 key components
• They are
• 1. History (HPI, ROS, PFSH)
• 2. Examination
• 3. Medical Decision Making

43
Coding Steps

• New Patients
• Within the 3 key components, there are 5 levels
  of service
• Remember to Consider the Key Components
  separately
• HPI, ROS, PFSH
• Examination
• Medical Decision Making

44
Example - New PatientThe Level of Service for a
new patient visit is determined by the lowest
level of service (1 through 5) of the three key
components
HPI, ROS, PFSH 4
Examination 4
Medical Decision Making 3 This is the lowest level
45
Coding Steps

• Established Patients
• Again Consider the Key Components Separately
• HPI, ROS, PFSH
• Examination
• Medical Decision Making
• The level of service (1 5) is determined by the
  level that appears in 2 of the three components,
  or by the middle level

46
Example Established Patient
HPI, ROS, PFSH 3 This is the middle level
EXAM 2
Medical Decision Making 4
47
Why is this?
48
Answer . . . There has to be a system, and
this is what AMA came up with.
49

• How to Steps of Coding

50
How to Steps of Coding Determine Level of
Medical Decision MakingDetermine Level of
History ComponentDetermine Level of Physical
Examination(You will need to reference the
chart examination notes for this)
51
Determine Level of Medical Decision Making

• Medical Decision Making consists of three
  sections
• Diagnosis or Management Problems
• Diagnostic Procedures
• Treatment of Management Options
• Level is determined by the level found in two of
  the three categories or the middle number if
  all three are different

52
Determine Level of Medical Decision Making
Section I Diagnosis or Management of Problems
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
One self-limited or minor problem Two or more self-limited or minor problems One stable chronic condition Acute uncomplicated illness One or more chronic illnesses with complications Two or more stable chronic conditions Undiagnosed new problem w/uncertain prognoses Acute illness with systemic symptoms Acute complicated injury One or more chronic illness with severe complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status
53
Determine Level of Medical Decision Making
Section II Diagnostic Procedures
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Lab X-ray EKG UA Ultrasound, etc. Venipuncture KOH Physiologic tests not under stress Pulmonary Function Barium Enema Arterial puncture Skin biopsies Physiologic tests under stress-cardiac stress tests Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography
54
Determine Level of Medical Decision Making
Section III Treatment or Management Options
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Rest Gargles Elastic bandages Dressings OTCs Minor surgery PT OT IVs without additives Minor surgery with risk factors Elective major surgeryno risk factors Prescription drug management IV fluids with additives Closed facture or dislocation treatment w/o manipulation Therapeutic nuclear medicine Elective Surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decision not to resuscitate or de-escalate care because of poor prognosis
55
How to Steps of Coding Determine Level of
History Component

• History component consists of three sections
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Patient, Family, and Social History (PFSH)

56
Determine Level of History Component Section I
History of Present Illness

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms

57
Determine Level of History Component Section II
Review of Systems

• Constitutional symptoms (fever, wt loss, etc.)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

58
Determine Level of History Component Section
III Patient, Family and Social History

• Past medical history
• Medication allergies
• Patients family history
• Patients social history
• Age-appropriate review of past and current
  activities
• Tobacco usage

59
History Component Matrix(Number of components of
each HPI, ROS PFSH required for each level)
New 99201 99202 99203 99204 99205
Established 99211 99212 99213 99214 99215
HPI 0 1 1 4 4
ROS 0 0 1 2 10
PFSH 0 0 0 1 2
60
How to of Coding Steps Determine Level of
Physical Examination

• Constitutional
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/Lympatic/Immunologic

61
Determine Level of Physical Examination of
body systems required for each level
New 99201 99202 99203 99204 99205
Established 99211 99212 99213 99214 99215
Exam 0 1 4 5 8
62
Coding Matrix Example
New Patient Established Patient
History 3 3
Exam 2 2
Medical Decision Making 3 3
Level of Coding 2 3
63
Coding Matrix Example
New Patient Established Patient
History 4 4
Exam 2 2
Medical Decision Making 4 4
Level of Coding 2 4
64
Coding Exercise
65
Coding Exercise for Evaluation/ Management
Services

• Suzy Q is a 16 y/o female with c/o
• severe female cramps - worse than usual.
• She states she took Midol and it only
• helped a little. She is a new patient.
• Document on the exam and encounter
• form to a level 3, using audit sheet
• as reference.

66
(No Transcript)
67
(No Transcript)
68
How to Verify this is correct level of
documentation to support level 3
69
(No Transcript)
70
Count the components
HRI 1 - Midol ROS 1 - cramps PFSH -
0 ___________ Level 3
Exam 1-const 2-Abd 3-back
4-genito ____________ Level 3
Med Decision - acute/uncomp - OTCs ___________
Level 3
71
(No Transcript)
72
Preventive Services
73
Preventive Services

• These visits include a comprehensive history and
  examination, as well as appropriate
  counseling/anticipatory guidance/risk factor
  reduction, interventions, and the ordering of
  age-appropriate laboratory/diagnostic procedures.

74
Preventive Services

• Comprehensive in a preventive service
  examination is not synonymous with a
  comprehensive E/M examination.

75
Preventive Service Codes
Age New Established
lt 1 99381 99391
1-4 99382 99392
5-11 99383 99393
12-17 99384 99394
18-39 99385 99395
40-64 99387 99397
65 99387 99397
76
Preventive Services

• Appropriate ICD-9 codes would be
• V20.2 for a Routine Infant or Child Health Check
• V70.3 for a Sports Physical

77
Preventive Services

• Additional services provided at the time of the
  visit should be reported with their specific CPT
  codes listed separately
• Examples
• Snellen Test
• Laboratory
• Immunizations
• Administration of Immunizations

78
Common Pitfalls inCoding
79
ICD-9 CM (Clinical Modification) Coding
Guidelines Order to list ICD-9 codes

• Coding Order is Important
• Acute Reason patient is being seen needs to be
  listed first.
• Co-morbid diagnosis affecting treatment of
  principal diagnosis are listed next.
• List all other documented conditions coexisting
  at the time of the visit that require or affect
  patient care, treatment or management. Chronic
  diseases may be listed as often as they are
  treated

80
ICD-9-CM Coding Guidelines

• DO NOT CODE
• Conditions previously treated that no longer
  exist.
• Conditions that do not affect treatment or
  management at the current visit.
• Rule-out, suspected, questionable or probable
  diagnoses.

81
ICD-9-CM Coding Guidelines Review of Systems
Documentation

• Cannot say all other negative
• Must list pertinent and negative findings
• Must have a way to determine which systems were
  reviewed
• A check list is acceptable

82
About Time With the Patient

• Do not base your level of service on time spent
  with patient.
• Time only comes into play if you are billing for
  counseling within an acute visit or if all you
  are doing is counseling

83
Sports Physicals

• They are not meant to be comprehensive physicals
  their focus is different
• Check www.aafp.org for an appropriate form
• You can bill for a complete PE and a sports PE
  within the same year

84
Acute Problems within a Comprehensive Physical

• When doing a preventive health visit (V20.2) and
  there is a separate health acute problem you
  can list both the preventive health visit code
  (first) and the acute visit code (second) BUT
  THERE MUST BE ICD-9 CODES THAT JUSTIFY BOTH
• (the billing department must add a modifier)

85
Be sure to know the Reason for the Visit
86
Late Effects of Burns

• Late effects means the burn has healed. There
  should not be dressing changes.

87
Counseling Visits

• Counseling visits are when client comes in to
  discuss a problem only. No hands are laid on the
  patient.

88
ExampleDietary Surveillance Counseling

• There must be a dietary problem in order to
  justify this code.

89
Be Specific with the codes you use
90
784.1 Throat Pain

• EXCLUDES
• Dysphagia 787.2
• Neck pain 723.1
• Sore throat 462
• Chronic 472.1

91
AGAIN - AboutOver-coding and Under-coding

• CPT and ICD-9 codes must always relate
• The first ICD-9 code you use drives the
  relationship to the CPT code

92
Poor example incorrect coding for documentation
See Handouts of Completed Note Sample 10a
(handout 9)Encounter Form 10a (handout 10)
93
(No Transcript)
94
(No Transcript)
95
Analysis of incorrect coding for documentation
96
Coding Audit Cheat Sheet Top half of form

• PATIENT IDENTIFIER____10a
• CODING AUDIT CHEAT SHEET
• TYPE OF SERVICE PROVIDED
• Preventive Health New patient ______
• Preventive Health Established patient ______
• Counseling Services No Physical Complaint
• Is time recorded in chart? YES _____ NO
  _____
• Is a counseling code used? YES _____ NO
  _____
• Evaluation / Management Visit where counseling
  determines time
• Is the total time of the visit recorded
  YES _____ NO _____
• Is the time spent in counseling recorded
  YES _____ NO _____
• Is a counseling code used? YES
  _____ NO _____
• Evaluation / Management Visit NEW PATIENT
• Evaluation / Management Visit ESTABLISHED
  PATIENT
• CPT ICD-9 CODES USED
• CPT CODES 99203 ICDE-9 CODES 625.3 DO
  THE CPT/ICD-9 CODES
• CORRELATE?
• YES __X___NO ______

97
Coding Audit Cheat SheetBottom Half of Form

• HISTORY AND EXAMINATION
• New 99201 99202 99203 99204 99205
• Established 99211 99212 99213 99214 99215
• HPI 0 1 1 4 4
• ROS 0 0 1 2 10
• PFSH 0 0 0 1 2
• EXAM 0 1 4 5 8
• CHART AUDIT LEVELS FOR E/M VISITS
• HPI, ROS, PFSH 3 NEW PATIENT LEVEL
  2
• Lowest level supports level
• EXAMINATION 2 ESTABLISHED PT LEVEL
  ____
• 2 of 3 or middle level supports level

98
Medical Decision Making Section I Diagnosis or
Management of Problems
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
One self-limited or minor problem Two or more self-limited or minor problems -One stable chronic condition -Acute uncomplicated illness One or more chronic illnesses with complications Two or more stable chronic conditions Undiagnosed new problem w/uncertain prognoses Acute illness with systemic symptoms Acute complicated injury One or more chronic illness with severe complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status
99
Medical Decision Making Section II Diagnostic
Procedures
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Lab X-ray EKG UA Ultrasound, etc. Venipuncture KOH Physiologic tests not under stress Pulmonary Function Barium Enema Arterial puncture Skin biopsies Physiologic tests under stress-cardiac stress tests Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography
Other levels of Diagnostic procedures do not
usually apply to SBHC, but you only need to have
2 of the 3 areas of medical decision making to
agree.
100
Medical Decision Making Section III Treatment
or Management Options
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Rest Gargles Elastic bandages Dressings OTCs Minor surgery PT OT IVs without additives Minor surgery with risk factors Elective major surgeryno risk factors Prescription drug management IV fluids with additives Closed facture or dislocation treatment w/o manipulation Therapeutic nuclear medicine Elective Surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decision not to resuscitate or de-escalate care because of poor prognosis
101
Unfortunately Because of this
documentation/coding error - you will not get
paid for this visit.This is why it is very
important to verify that charting supports all
levels of coding decision making.
102
Questions Answers