Post on 24-Oct-2020
Pennsylvania Academy of Family Physicians Foundation
Pittsburgh CME Conference
November 7 - 9, 2014
Billing and Coding Best Practices…Earn What You’re Worth Thomas Weida, MD, FAAFP, Penn State College of Medicine, Hershey, PA
Disclosures: Speaker has no disclosures and there are no conflicts of interest. The speaker has attested that their presentation will be free of all commercial bias toward a specific company and its products. The speaker indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices.
Capture the Coding, Outpatient
© Thomas Weida, M.D. 1
Thomas J. Weida, M.D.Professor, Penn State College of Medicine
© 2014, Thomas J. Weida, M.D. 2
Dr. Thomas Weida has no conflict of interest, financial agreement, or working affiliation with any group or organization.
1. Utilize proper documentation for CPT E&M coding
2. Apply proper CPT code use for common clinical situations, thereby avoiding under-coding or over-coding
3. Use medical decision making to guide E&M level
© 2014, Thomas J. Weida, M.D. 3
Capture the Coding, Outpatient
© Thomas Weida, M.D. 2
4
1. 992012. 992023. 992034. 992045. 992056. 992117. 992128. 992139. 9921410. 99215
5
1. 992112. 992123. 992134. 992145. 99215
6
1. 992112. 992123. 992134. 992145. 99215
Capture the Coding, Outpatient
© Thomas Weida, M.D. 3
None
© 2014, Thomas J. Weida, M.D. 7
Coding Captures What You Did, Not
Reimbursement
8
Element 99211 99212 99213 99214 99215
CC NA Required Required Required Required
HPI NA 1-3 1-3 4+ 4+
ROS N/A NA Pertinent 2-9 10
PFSH N/A N/A NA 1 of 3 1of each
Exam NA Focused Expanded Detailed Comp
Dx/Mgt NA Minimal Limited Multiple Extensive
Data NA Minimal Limited Moderate Extensive
Risk NA Minimal Low Moderate High
Hx
Px
Decision Making
locationqualityseveritydurationtimingcontextmodify fctassoc sx
2 of 3
One self limited problem
2 Minor self limited problemsOne stable chronic problemAcute simple illnessOTC Drug, PT, OT, Minor surgIV no additives
1 or > chronic problem withprogression or side effect
3 Stable Chronic IllnessesUndx new problem, uncertain pxAcute complicated injury Prescription drug
1 or > chronic with severe exacerbation
Threat to life or function
Abrupt neuro change
Parenteral controlled sub.
Major surgeryRx with intensivemonitoring
PennState Hershey Medical Center
2 of 3
© 2014, Thomas J. Weida, M.D. 9
New: A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
Established: A patient who has been seen within the past three years.
New > Three Years
Capture the Coding, Outpatient
© Thomas Weida, M.D. 4
10
Element 99201 99202 99203 99204 99205
CC Required Required Required Required Required
HPI 1-3 1-3 4+ 4+ 4+
ROS N/A Pertinent 2-9 10 10
PFSH N/A N/A 1 of 3 1 of each 1of each
Exam Focused Expanded Detailed Comp Comp
Dx/Mgt Minimal Minimal Limited Multiple Extensive
Data Minimal Minimal Limited Moderate Extensive
Risk Minimal Minimal Low Moderate High
Hx
Px
Decision Making
locationqualityseveritydurationtimingcontextmodify fctassoc sx
2 of 3
One self limited problem
2 Minor self limited problemsOne stable chronic problemAcute simple illnessOTC Drug, PT, OT, Minor surgIV no additives
1 or > chronic problem withprogression or side effect
2 Stable Chronic IllnessesUndx new problem, uncertain pxAcute complicated injury Prescription drug
1 or > chronic with severe exacerbation
Threat to life or function
Abrupt neuro change
Parenteral controlled sub.
Major surgeryRx with intensivemonitoring
PennState Hershey Medical Center
3 of 3
Overall MDM Problem Points
Data Points Level of Risk
Straightforward Complexity (992x2)
1 1 Minimal
Low Complexity(992x3)
2 2 Low
Moderate Complexity(992x4)
3 3 Moderate
High Complexity(992x5)
4 4 High
© 2014, Thomas J. Weida, M.D. 11
Need Two of Three to Qualify for Level
© 2014, Thomas J. Weida, M.D. 12
Problem Points
Self limited or minor (maximum of 2) 1 eachEstablished problem, stable or improving 1 eachEstablished problem, worsening 2 eachNew problem, no additional work up planned (maximum of 1) 3New problem, with additional work up planned 4
Capture the Coding, Outpatient
© Thomas Weida, M.D. 5
Data Reviewed PointsReview or order clinical laboratory tests 1Review or order radiology tests (except echo or heart cath) 1Review or order medicine test (PFT, EKG, Cardiac Cath, Echo, etc. *) 1Discuss test with performing physician 1Independent review of tracing, image or specimen (i.e. EKG, KOH, UA)
2
Decision to obtain old records 1Review and summation of old records 2
13
* EKGs, EEGs, PFTs, echocardiograms, cardiac catheterizations, cardiac stress tests, audiometry, speech or swallow studies, pacemaker interrogations, arterial or venous doppler studies, plethysmography, non-invasive arterial studies (such as ABIs), transcranial doppler studies, allergy testing, sleep studies, EMGs, evoked potentials, tensilon testing and nutritional assessments
Risk Presenting Problems
Diagnostic Options Management Options
Minimal (992x2)
Minimal Routine Labs, EKG, X-rays, USN, Echo, EEG
Advice
Low (992x3)
Low PFT, Contrast X-rays, ABG, Skin Biopsy
OTC, PT, OT, Minor Surgery, IV – no additives
Moderate (992x4)
Medium Stress tests, endoscopies, Cardiac cath, LP, Thoracentesis
Prescription Drugs, IV’s with additives, Major surgery – no risk factors, Minor surgery with risk, Closed fracture, Nuclear med treatment
High (992x5)
High Cardiovasc imaging with risk factors, EP studies, Endoscopy with risk, Discography
Surgery with risk, Emergency surgery, Narcotics, Drug therapy with extensive monitoring, DNR decision
© 2014, Thomas J. Weida, M.D. 14
15
1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment
Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)
Abrupt neuro status change (TIA, Sx, weakness, sensory loss)
4 HPI elements 10 ROS 1 of each PFSH
Comprehensive (general multisystem or complete single organ)
Decision Making History
Physical
40 min
Capture the Coding, Outpatient
© Thomas Weida, M.D. 6
16
3 chronic stable illnesses 2+ or more chronic stable
illnesses 1+ chronic illness with
exacerbation Undiagnosed new problem
with uncertain diagnosis Acute illness with systemic
symptoms Acute complicated injury
4 HPI elements 2-9 ROS 1 of 3 PFSH
Detailed (affected area and related organ system)
Decision Making History
Physical
25 min
17
2 or more self limited problems
1 stable chronic illness acute uncomplicated illness
(cystitis, sprain)
1-3 HPI elements
Pertinent ROS
Expanded problem focused
Decision Making History
Physical
15 min
18
1 or more chronic illness with severe exacerbation, progression or side effects of treatment
Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)
Abrupt neuro status change (TIA, Sx, weakness, sensory loss)
4 HPI elements 10 ROS 1 of each PFSH
Comprehensive (general multisystem or complete single organ)
Decision Making History
Physical
60 min
Capture the Coding, Outpatient
© Thomas Weida, M.D. 7
19
3 chronic stable illnesses 2+ or more chronic stable
illnesses 1+ chronic illness with
exacerbation Undiagnosed new problem
with uncertain diagnosis Acute illness with systemic
symptoms Acute complicated injury
4 HPI elements 10 ROS 1 of each PFSH
Comprehensive(general multisystem or complete single organ)
Decision Making History
Physical
Looks like a 99215
45 min
20
2 or more self limited problems
1 stable chronic illness acute uncomplicated illness
(cystitis, sprain)
4 HPI elements 2-9 ROS 1 of 3 PFSH
Detailed (affected area and related organ system)
Decision Making History
Physical
Looks like a 99214
30 min
Overall MDM Problem Points
Data Points Level of Risk
Straightforward Complexity (992x2)
1 1 Minimal
Low Complexity(992x3)
2 2 Low
Moderate Complexity(992x4)
3 3 Moderate
High Complexity(992x5)
4 4 High
21
Need Two of Three to Qualify for Level
Established problem, stable or improving – 1 ptEstablished problem, worsening – 2 pt eachNew problem, no additional work up planned (maximum of 1) 3 pt
Prescription Drugs
Capture the Coding, Outpatient
© Thomas Weida, M.D. 8
22
20 min
10 min
One self limited problem
Focused exam 1-3 HPI elements
One self limited problem
Expanded problem focused exam
1-3 HPI elements Pertinent ROS
Looks like a 99213
23
BP check by nurse Weight check for CHF Lab draw Picking up prescription refill Picking up return to work or school
certificate. (If mail or call in, no CPT code allowed)
May not require physician presence
5 min
“Coding from the Bottom Up,” Thomas Weida, David O’Gurek, Family Practice Management, November 2008
24
The specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances.
Face-to-face for office and outpatient
Unit/floor for hospital and inpatient
Time is not a criteria for level of service.
99205 – 60 min99204 – 45 min99203 – 30 min
99215 – 40 min99214 – 25 min99213 – 15 min
Capture the Coding, Outpatient
© Thomas Weida, M.D. 9
25
Counseling: a discussion with a patient and/or family concerning: Diagnostic results, or recommended studies Prognosis Risks & benefits of treatment Importance of compliance Risk factor reduction Patient and family education
Not just psychological counseling If counseling > 50% of visit time, can use
counseling documentation for level.
Examples - Outpatient
26
1. 992112. 992123. 992134. 992145. 99215
What else is needed?
4 HPI
2-9 ROS or
1 of PFSH
Detailed physical (affected and related organ system)
27
What else is needed?1. 992112. 992123. 992134. 992145. 99215
•1-3 HPI elements
•Pertinent ROS or
•Expanded problem focused physical
Capture the Coding, Outpatient
© Thomas Weida, M.D. 10
28
1. 992112. 992123. 992134. 992145. 99215
29
1. 992112. 992123. 992134. 992145. 99215
30
1. 992112. 992123. 992134. 992145. 99215
Capture the Coding, Outpatient
© Thomas Weida, M.D. 11
31
Overall MDM Problem Points
Data Points
Level of Risk
Straightforward Complexity (992x2)
1 1 Minimal
Low Complexity(992x3)
2 2 Low
Moderate Complexity(992x4)
3 3 Moderate
High Complexity(992x5)
4 4 High
32
Problem Points
Self limited or minor (maximum of 2) 1 each
Established problem, stable or improving 1 each
Established problem, worsening 2 each
New problem, no additional work up planned (maximum of 1) 3
New problem, with additional work up planned 4
33
1. 992112. 992123. 992134. 992145. 99215
Capture the Coding, Outpatient
© Thomas Weida, M.D. 12
34
1. 992012. 992023. 992034. 992045. 99205
Medical decision making of 99214 History and physical of 99215
35
1. 992112. 992123. 992134. 992145. 99215
36
1. 992012. 992023. 992034. 992045. 99205
Capture the Coding, Outpatient
© Thomas Weida, M.D. 13
37
1. 992112. 992123. 992134. 992145. 99215
38
Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
Best to have two different diagnoses E&M -25 and procedure code Example: laceration which you evaluate
and then repair with sutures Document two independent notes
CPT 2000, pg. 403-404
© 2014, Thomas J. Weida, M.D. 39
3 chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain
diagnosis Acute illness with systemic symptoms Acute complicated injury
Capture the Coding, Outpatient
© Thomas Weida, M.D. 14
40
1. 992012. 992023. 992034. 992045. 992056. 992117. 992128. 992139. 9921410. 99215
41
1. 992112. 992123. 992134. 992145. 99215
42
1. 992112. 992123. 992134. 992145. 99215
Capture the Coding, Outpatient
© Thomas Weida, M.D. 15
43
1. 02. 13. 24. 35. 46. 5 – 77. > 8
Medicare Rates
© 2014, Thomas J. Weida, M.D. 44
Undercoded/day 1 2 3 4 5 8
Non facility $
8,331.60 $
16,663.20 $
24,994.80 $
33,326.40 $
41,658.00 $
66,652.80
Facility$
6,903.60 $
13,807.20 $
20,710.80 $
27,614.40 $
34,518.00 $
55,228.80
Pull 10 notes and check coding against easy to use guidelines.
Mentally calculate how much revenue lost Kick self Repeat process till no longer kicking self Simple
© 2014, Thomas J. Weida, M.D. 45
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