2005 Coding Update and Primer

2009 Coding Presentation Presentation for:

San Diego County Medical Society Jamie, Montoya, CPC Karrie May, CPC Senior Account Managers

www.chmbsolutions.com

Karrie May, CPC Ms.

May is a Senior AR Manager for CHMB Practice Management Services.

Founded in 1995, CHMB is a leading provider of outsourced business services for health- care organizations. Ms.

May has over 20 years experience in physician billing, claims processing and collections, working initially for Prudential Insurance Company, then Scripps Clinic in San Diego and has been with CHMB since 1997. She has extensive knowledge in various medical specialties including Cardiology, Oncology, Colon/Rectal Surgery and Otolaryngology. She is a Certified Professional Coder (CPC), member of the American Academy of Professional Coders and continues to build her knowledge base and keep her certification up to date by attending billing and coding seminars. As

a Senior AR Manager, she manages her team of employees whom are responsible for data entry, quality assurance and posting of all medical services and corresponding transactions including appeals and collections from insurance and private responsible parties. Ms. May is also responsible for auditing physician charts for compliance and reimbursement and regularly provides interpretation of payor, MSO and IPA contracts for CHMB clients.

Jamie Montoya, CPC ď ľ

Ms. Montoya is a Senior AR Manager for CHMB Practice Management Services. Founded in 1995, CHMB is a leading provider of outsourced business services for health- care organizations.

ď ľ

Ms. Montoya has over 18 years experience in physician billing and collections, working in private practices for various specialties. Ms. Montoya has extensive knowledge in billing and coding includes Orthopedics, General Surgery, Pediatrics, Pulmonology, and Oncology as well as Family Practice, Trauma and Emergency Medicine. She continues to build her knowledge base and keep her certification up to date by attending billing and coding seminars.

ď ľ

As a Senior AR Manager, she manages her team of employees whom are responsible for data entry, quality assurance and posting of all medical services and corresponding transactions including appeals and collections from insurance and private responsible parties. Ms. May is also responsible for auditing physician charts for compliance and reimbursement and regularly provides interpretation of payor, MSO and IPA contracts for CHMB clients.

Purpose of presentation Preventative medicine and screening tests guidelines and use E&M Coding Guidelines

Preventative Medicine Services Codes 99381-99387 for New Patients Codes 99391-99397 for established These codes are used to report the preventative medicine evaluation and management of infants, children, adolescents and adults.

Preventative Medicine If during a preventative (yearly physical) a preexisting or new problem is encountered and it is significant enough to require additional work to perform the key components of a problem-oriented E/M service then the appropriate office code should be reported.

Adding modifier 25 to indicate that it is separately identifiable.

Preventative Visit If the problem is insignificant or does not warrant the additional work and the performance of the key components for an additional E/M visit then an additional visit should not be reported.

Ie an established patient with a chronic condition but it is under control would not warrant the additional visit

Preventative Medicine guide

Preventative Medicine Guide

Prostate Cancer Screening Digital Rectal Exam

G0102

$20.47

Screening PSA

G0103

$25.70

Payable once every 12 months V76.44 Special screening for malignant neoplasms, prostate

Screening Pap Smears Q0091 Screening pap smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory.

Payable once every 24 months if the patient is low risk or every 12 months if the patient is high risk.

Medicare allowable 2008

$41.70

Screening pap smears Patients with low risk should be billed with these diagnosis codes V76.2

Special screening for malignant neoplasm, cervix

V76.49 Special screening for malignant neoplasm, other Sites V76.47 V72.31

Special screening for malignant neoplasm, vagina Routine gynecological examination

Patients with high risk should be billed with this diagnosis code V15.89 Other

Pelvic and clinical breast exam G0101

$35.93

Payable once every 24 months for low risk once every 12 if high risk V76.2 V76.47 V76.49 V72.31 High risk diagnosis V15.89

EKG DURING PHYSICAL You may bill for an EKG during a physical.

Code 93000

$23.37

DX should be V71.7 observation for suspected cardiovascular disease. If after you do the ekg there is a diagnosis you may use that instead.

Welcome to Medicare Code G0344: Initial preventative physical exam; face to face visit, services limited to new beneficiary during the first six months of Medicare enrollment.     



The IPPE includes the following components: Measurement of height weight, blood pressure, and visual acuity Performance and interpretation, of a screening electrocardiogram (must be billed on claim) Review of the individual’s medical and social history Review of the individual’s potential risk factors for depression, functional ability and level of safety with the goal of health promotion and disease detection Education, counseling, and referral with respect to screening and preventive services currently covered under Medicare Part B

Welcome to Medicare cont As required by statute, the IPPE benefit always includes a screening EKG, which should be billed using one of the following HCPCS codes: 

G0366 Full. EKG service (tracing, interpretation, and report)



G0367 EKG technical component only



G0368 EKG professional component only

Smoking and Tobacco use cessation services 

Effective March 22, 2005, Medicare Part B covers two new levels of counseling, intermediate and intensive for smoking and tobacco use cessation.



Patients must be competent and alert at the time that services are provided.



Beneficiary must have a condition that is adversely affected by smoking or tobacco use



Metabolism or dosing of a medication. used to treat a condition has adversely been affected by smoking or tobacco use.

Smoking and Tobacco Cessation services 

Medicare will cover 2 cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions in a 12-month period.



Medicare covers 2 types of counseling:



Intermediate cessation counseling is 3 to 10 minutes per session G0375 Greater than 3 to 10 minutes per session

 

Intensive cessation counseling is greater than 10 minutes per session. G0376 Greater than 10 minutes per session

E&M CODING BASICS PURPOSE OF THIS PART IS TO HELP YOU DECIPHER THE CODING GUIDELINES REVIEW REQUIREMENTS FOR DOCUMENTATION FOR NEW AND ESTABLISHED PATIENT VISITS

New vs. Established Patient?  New

Patient

– Not seen by you within past three years And – Not seen by another physician in your specialty group

 Established

Patient

– Seen by you within the past three years Or – Seen by another physician in your specialty group

7 Components of Evaluation and Management (E/M) 

History



Examination



Medical Decision Making



Counseling



Coordination of Care



Nature of Present Problem



Time

Three Key Components History  Examination  Medical Decision Making 

Key Component Requirement 3 of 3 REQUIRED  New outpatient  Inpatient admission  Consultation (in or out)  Hospital Observation  Emergency Department

2 of 3 REQUIRED  Established patient  Subsequent Inpatient Days  Inpatient Follow-up Consult

Key Components Type of Patient Number of Components New Patient 3 of 3 Established Patient 2 of 3

History

Exam

MDM

S O A P Charting

S O Objective Data Assessment A Plan P

Subjective Data

•History of the Present Illness, Past Illness, etc •Usually in the “patients words” •Documentation of the Examination performed •Diagnosis •Treatment options •Plan of care

History 







The most neglected component Almost always discussed But usually not documented IF IT’S NOT DOCUMENTED IT DID NOT HAPPEN!!!!

Elements of History 

Chief Complaint



HPI – Chronological account of signs & symptoms of the present condition

ROS – Review of Systems  PFSH 

– Past Medical, Family, Social History

CC - Chief Complaint “Why has the patient sought medical care?” 

Usually in the patient’s words



Chief Complaint will establish the “medical necessity”



Must clearly be reflected in the patient chart

No CC Examples ď ľ

Pre-Operative visit often does not have the CC or the medical necessity to bill for the service (not always included in the global surgical package)

ď ľ

Follow-up visits: Especially when the patient is doing well.

History of Present Illness (HPI) 







Location

– Area of the body where the problem, pain or injury is located – Where does it hurt?

Quality

– Characteristics of grade of illness – What is the patient feeling?

– Stabbing, throbbing, dull, sharp



– When does the problem occur?

– Morning? Night? Intermittent?



Duration

– Describing when the symptoms first occurred – Hours? Weeks? Days?

Context

– “Big Picture” – Circumstances in which a particular event occurs



Modifying Factors

– What has the patient done to relieve the discomfort?

– What makes it better? What makes it worse?

Severity

– How hard it is to endure?

– Level or magnitude of presenting problem – Scale of 1 to 10

Timing



Signs/Symptoms

– Other complaints the patient may have that are related to the chief complaint

History of Present Illness (HPI) 

Brief – 1 to 3 Elements



Extended – 4 or more Elements OR – At least 3 chronic or inactive conditions  Osteoarthritis  Rheumatoid

Arthritis  Carpal Tunnel Syndrome

Review of Systems 



A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced

            

Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunology

Review of System Examples              

Constitutional: Fever, weight loss, weight gain Eyes: Visual difficulties/changes, wears glasses Ears, Nose, Mouth, Throat: Tender gums, sensitive tongue, dry mouth Cardiovascular: Palpitations, edema, chest pain Respiratory:Wheezing, shortness of breath, orthopnea Gastrointestinal: Nausea, abdominal pain, vomiting Genitourinary: Frequent urination, hematuria Musculoskeletal: Joint pain, swollen joint, difficulty walking Integumentary: Skin irritation, blemishes, redness in skin Neurological: Loss of consciousness, seizures, numbness Psychiatric: Anxiety, sadness Endocrine: Hypoglycemia, diabetes Hematologic/Lymphatic: Tender lymph nodes, easy bruising, anemia Allergic / Immunologic: Seasonal allergies, frequent infections

Levels of Review of Systems 

Problem Pertinent – The patient’s positive responses and pertinent negatives for the system related to the problem



Extended – 2-9 systems must be performed and documented



Complete – At least 10 organ systems must be performed and documented

Past, Family and/or Social History PFSH Consists of a review of 3 areas: 

Past History – illnesses, operations, injuries, treatments, allergies, current medications



Family History – Health status or cause of death of parents, siblings and children, specific disease(s) related to the chief complaint



Social History – Age appropriate review of past and current activities; living arrangements, marital status, current employment, use of drug, alcohol and tobacco, level of education, sexual history or other relevant social factors

PFSH 

Pertinent: 1 element



Complete: – 3 elements must be documented for new patients – 2 out of the 3 elements must be documented for established or ER patients

History Documentation Guidelines ď ľ

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.

� History Form completed on ______reviewed and revised. Provider Initials

History Documentation 

ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. Physician must document that it was reviewed, there must be a notation supplementing or confirming the information recorded by others.  I agree with the above nurses notes. Provider Initials  I agree with the above nurses notes with the following additions: ___________________________________ Provider Initials  History Form completed by the patient was reviewed.

Provider Initials

History Documentation 

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining the history.

– Patient spoke __________language, interpreter not available.

– Patient confused/semi conscious etc, unable to obtain history.

History: Putting it all together Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

HPI

Brief 1-3

Brief 1-3

Extended 4 or more

Extended 4 or more

ROS

None

Pertinent to problem (1 system)

Extended 2-9

Complete 10 or more

PFSH

None

None

Pertinent 1 area

Complete 2 or 3 areas

Evaluation and Management Documentation Guidelines 

1995 – Based upon the number of body areas and organ systems examined and documented  Problem

Focused  Expanded Problem Focused  Detailed  Comprehensive 

1997 – Two types of examination  Multi-system  Single

System

1995 Examination Documentation Guidelines

1995 Exam Guidelines Body Areas & Organ Systems 

Body Areas – Head, including the face – Neck – Chest, including breasts & axillae – Abdomen – Genitalia, groin, buttocks – Back, including spine – Each extremity



Organ Systems – Constitutional – Eyes – Ears, nose, mouth & throat – Cardiovascular – Respiratory – Gastrointestinal – Genitourinary – Musculoskeletal – Skin – Neurologic – Psychiatric – Hem/Lymph/Immune

1995 Exam Guidelines Four Levels of Exams 

Problem Focused – A limited exam of the affected body area or organ system



Expanded Problem Focused – A limited exam of the affected body area or organ system and other symptomatic or related organ system(s)



Detailed – An extended exam of the affected body area(s) and other symptomatic or related organ system(s)



Comprehensive – A general multi-system exam or complete exam of a single organ system

1997 Examination Documentation Guidelines

1997 Exam Guidelines Two Types of Exams 

General MultiSystem – Comprehensive:  Include

at least nine organ systems or body areas  For each system/area selected, all elements of the exam should be performed



Single Organ System – Comprehensive:  Include

all elements of that

system  Document every element in a shaded area and at least one element in an unshaded area

Type of Exam (1997) 



General Multi-System Exam or a Single Organ System Exam may be performed by any physician regardless of specialty.

The type and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).



Single Organ Exams: – Cardiovascular – Ears, Nose, Mouth, Throat – Eyes – Genitourinary (Female) – Genitourinary (Male) – Hematologic/Lymphatic/ Immunologic – Musculoskeletal – Neurological – Psychiatric – Respiratory – Skin

Multi-System Examination (1997) 

Problem Focused Exam – One to five elements identified by a bullet



Expanded Problem Focused Exam – At least 6 elements/bullets.



Detailed Exam – At least 12 elements in two or more organ systems or body areas.



Comprehensive Exam – At least 9 organ systems or body areas. All elements of the exam identified by a bullet ( for each are/system, documentation of at least 2 elements identified by a bullet is expected

Single Organ System Exam (1997) 

Problem Focused Exam – One to five elements identified by a bullets



Expanded Problem Focused Exam – At least 6 elements/bullets



Detailed Exam (other than eye and psych exam) – At least 12 elements/bullets



Comprehensive Exam – All elements that are shaded and at least one element that is unshaded is expected

General Multi-System Exam 

Constitutional: – Measurement of any three of the following 7 vital signs – – – – – – – 

1.

2.

3.

4.

5.

6.

7.

sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (may be measured and recorded by ancillary staff)

General appearance of patient (eg., development, nutrition, deformities, attention to grooming)

General Multi-System Exam 

Eyes – Inspection of conjunctivae and lids – Examination of pupils and irises – Opthalmoscopic examination of optic discs (e.g. size, C/D ration, appearance) and posterior segments



Ears, Nose, Mouth and Throat – External inspection of ears and nose – Otoscopic exam of external auditory canals and tympanic membranes – Assessment of hearing – Inspection of nasal mucosa, septum and turbinates – Inspection of lips, teeth and gums – Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

General Multi-System Exam 

Neck – Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus) – Examination of thyroid (e.g. enlargement, tenderness, mass



Respiratory – Assessment of respiratory effort – Percussion of chest (e.g. dullness, flatness, hyperresonance) – Palpation of chest (e.g. tactile fremitus) – Ausculation of lungs (eg breath sounds, rubs)



Chest – Inspection of breasts (e.g. symmetry, nipple discharge) – Palpation of breasts and axillae (e.g. masses or lumps, tenderness)

General Multi-System Exam  Cardiovascular

– Palpation of heart (e.g. location, size, thrills) – Ausculation of heart with notation of abnormal sounds and murmurs Examination of: – Carotid arteries (e.g. pulse amplitude, bruits) – Abdominal aorta (e.g. size, bruits) – Femoral arteries (e.g. pulse amplitude, bruits) – Pedal pulses (e.g. pulse amplitude) – Extremities for edema and/or varicosities

General Multi-System Exam 

Gastrointestinal

– – – – – 

Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated

Lymphatic

– – – – –

Palpation of lymph nodes in two or more areas Neck Axillae Groin Other

General Multi-System Exam 

Genitourinary Male

– Examination of the scrotal contents – Examination of the penis

Female

– Pelvic examination (with or without specimen collection for smears and cultures) including – Examination of external genitalia – Examination of urethra (masses, tenderness, scarring) – Examination of bladder (fullness, masses, tenderness) – Cervix (general appearance, lesions, discharge) – Uterus (size, contour, position, mobility, tenderness, consistency, descent or support – Adnexa/parametria (masses, tenderness, organomegaly, nodularity)

General Multi-System Exam  Musculoskeletal

– Examination of gait and station – Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, infections, nodes) – Examination of joints, bones and muscles of one or more of the following six areas:  Head

and neck  Spine, ribs and pelvis  Right upper extremity/Left upper extremity  Right lower extremity/Left lower extremity

General Multi-System Exam Musculoskeletal cont..

Exam to include:

– Inspection and or palpation with notation of presence of any misalignment, asymmetry, crepitation, defect, tenderness, masses, effusions.

– Assessment of range of motion with notation of any pain, crepitation or contracture – Assessment of stability with notation of any dislocation (luxation) subluxation or laxity – Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

General Multi-System Exam Neurological/Psychiatric



– –

Test cranial nerves with notation of any deficits.

Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg. Babinski) Examination of sensation (eg. By touch, pin, vibration, proprioception)

–

Brief assessment of mental status including:





– –

Description of patient’s judgement and insight Orientation to time, place and person

–

Mood and affect (eg., depression, anxiety, agitation)

Skin – –

Inspection of skin and subcutaneous tissue Palpation of skin and subcutaneous tissue

Examination Documentation 





Specific abnormal & relevant negative findings of the exam of the affected or symptomatic body area(s) should be documented. A notation of “abnormal” without elaboration is insufficient Abnormal or unexpected findings of the exam of the unaffected or asymptomatic body area(s) or Organ system(s) should be described A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or to asymptomatic organ system(s)

Complexity of Medical Decision Making Can determine the level of service  3 elements (2 of 3) 

– Number of diagnosis/manageme nt options – Amount of data reviewed/ordered – Patient risk

4 Types of Medical Decision Making Straightforward  Low Complexity  Moderate Complexity  High Complexity 

MDM Documentation 

Presenting Problem with an established diagnosis – improved, well controlled, resolving or resolved – inadequately controlled, worsening, or failing to change as expected



Presenting Problem without an established diagnosis – May be stated in a form of differential diagnoses or as a “possible” “probable”, or “rule out” diagnosis.

– (Do not code these, however, they will support the MDM)

Number of Diagnosis or Treatment Options A

Number of Diagnoses or Treatment Options Problems to Exam Physician Number X Points = Result

Self-limited or minor (stable, improved or w orsening) Est. problem (to examiner); stable, improved Est. problem (to examiner); w orsening New problem (to examiner); no additional w orkup planned New prob. (to examiner); add. w orkup planned

Max = 2

1

Max = 1

1 2 3

4 TOTAL Bring total to line A in Final Result for Complexity

Amount and/or Complexity of Data to be Reviewed B Am ount and/or Com plexity of Data to Be Reviewed Data to Be Reviewed

Points

Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results w ith perf orming physician 1 Decision to obtain old records and/or obtain history f rom someone other than patient 1 Review and summarization of old records and/or obtaining history f rom someone other than patient and/or discussion of case w ith another health care provider 2 Independent visualization of image, tracing or specimen itself (not simply review of report) 2 TOTAL Bring total to line B in Final Result f or Complexity

Putting it all together Level

Number of Dx

Amount of Data

Risk

SF

Minimal

Minimal/None

Minimal

Low

Limited

Limited

Low

Mod

Multiple

Moderate

High

Extensive

Extensive

Moderate High

Putting the 3 Key Components Together History Exam Medical Decision Making 

DON’T FORGET! – New Patients requires 3 out of 3 – Established Patient only needs 2 out of 3  Note:

Including the Medical Decision Making as one of the key components will increase your accuracy matching the code to the presenting problem

New Patient History

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Comprehensive

Examination

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Comprehensive

Medical Decision Making

SF

SF

Low

Moderate

High

Level

99201

99202

99203

99204

99205

Established Patient History

Minimal Problem that

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Examination

may not require

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Medical Decision Making

the presence of a physician

SF

Low

Modera te High

Level of Service

99211

99212

99213

99214

99215

Time 

Face to Face – Counseling &/or coordination of care – Dominates over 50% of encounter – Document the total time spent with the patient



Unit/Floor time

Time Documentation  Can

be coded by time:

– About 35 minutes of a 45 minute appointment was spent discussing treatment options, surgery risks and complications.  Cannot

be coded by time:

– A long discussion was held with the patient as to his underlying diagnosis.

Course of treatment plan from conservative management to arthroscopic surgery to total knee arthroplasty was discussed with the patient.

Hospital Services 



Only one physician can bill a hospital admit Use caution when rounding on a patient that is being seen by the primary care (refer to concurrent care guidelines)

Hospital Admits   

99221: D/D/Low 99222: C/C/Mod 99223: C/C/High

Follow-up Hospital Visits   

99231: PF/PF/Low 99232: EPF/EPF/Mod 99233: D/D/High

Discharge  

99238: <30 minutes 99239: >30 minutes (time must be documented in the chart to use this code)

Percent of Total

E&M Variance Analysis sample E&M Code Usage 140 120 100 80 60 40 20 0

140 120 100 80 60 40 20 0

9921199212992139921499215

9921199212992139921499215

Normal

High Complexity

Normal

Low Complexity

Internet Resources 

Www.physicianspractice.com

On-line tools for various topics



www.aafp.org/x20091.xml

On-line tools for various topics



www.cms.hhs.gov/statistics/feeforservice/default.asp Usage



www.medicalmanagement.com On-line tools for fee schedules



www.cms.hhs.gov/providers New codes (CPT and ICD-9) – This is also the site for LMRPs and clia waived lab tests www.palmetto.com Southern and Northern CA Medicare – Part B newsletters, fee schedules, etc… www.chmbsolutions.com CHMB Billing and Consulting Services





E/M

Professional Associations www.aapc.com www.mgma.com www.camgma.com

American Academy of Professional Coders (AAPC) Medical Group Management Association (MGMA) California MGMA (CMGMA)

www.cmanet.org

California Medical Association (CMA)

www.sdcms.org

San Diego County Medical Society (SDCMS)

www.hfma.org

Healthcare Financial Management Association (HFMA)