B4: Crack the Code: B4: Crack the Code: Addressing Billing Code IssuesAddressing Billing Code Issues

Laura Brey, Training Director, NASBHC

lbrey@nasbhc.org

919-866-0920

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Welcome and ExpectationsWelcome and Expectations

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ObjectivesObjectivesThe 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

– Explain the rational for conducting routine medical record review and coding compliance audits in SBHC settings

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Coding Background Coding Background andand TerminologyTerminology

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Coding DefinitionCoding Definition

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

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Types of Coding 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)

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Coding Is Not The Same As Billing

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Coding is Medicare DriveCoding is Medicare Drive

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

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SBHC CodingSBHC 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.

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Why Code Correctly?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

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The Coding Process has 2 PartsThe 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)

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When a provider is under-When a provider is under-coding they tell the wrong storycoding 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.

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There Are Two Coding There Are Two Coding Guidelines - 1995 & 1997Guidelines - 1995 & 1997Both 1995 and 1997 guidelines are

approved for use by CMSAgencies may specify use of 1995 or

1997 guidelines1997 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

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Coding Guidelines Coding Guidelines 1995 vs. 19971995 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

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FraudFraud

Intentional deception or misrepresentation– Deliberately billing for services not

performed– Unbundling of services– Intentionally submitting duplicate claims

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AbuseAbuse

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

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ErrorsErrors

Accept it, you will make them.

Your best defense is having a plan for your coding and being able to explain it.

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Over-coding and Under-codingOver-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

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Coding Does Not Equal Good

Medicine

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But - Coding is Good But - Coding is Good DocumentationDocumentation

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CPT Codes document:CPT Codes document:

Level of Service

Procedures Provided

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Examples of CPT codesExamples of CPT codes

Evaluation &

Management 99211

99212 99213 99214 99215

Preventive Health99391993929939399394993959939799397

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ICD-9 and DSM4 Codes ICD-9 and DSM4 Codes document:document:

The reason behind the visit

(They must support the CPT codes)

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General Coding PrinciplesGeneral Coding Principles

Coding gets you paid for your servicesCoding can be used to justify the need

for services to your funders

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Coding with ICD-9Coding 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 existsUse a 4-digit code only if there is no 5-

digit code with the same categoryUse 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

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ICD-9-CM CodesICD-9-CM Codes

Range from 001.0 to V82.9They identify:

– Diagnoses– Symptoms– Conditions– Problems– Complaints– Other reason for the procedure, service, or

supply provided

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ICD-9-CM CodesICD-9-CM Codes Three volumes

– Volume 1 Tabular List of DiseasesNotes 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 ProceduresUsed almost exclusively for hospital

services

PS: (All 3 Volumes are generally found in one binding)

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““V” CodesV” 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

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““V” CodesV” Codes

Can be used as a:– Solo Code– Principal code– Secondary code

May represent check-ups, screenings, administrative requests, prescription refills

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Rules for CodingRules for Coding Outpatient Visits Outpatient Visits

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Determine Type of Office Visit 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 VisitsNew Patients vs. Established Patients

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Determine Medical NecessityDetermine Medical Necessity

Services are reasonable and necessary for the diagnosis and treatment of illness or injury.

All payors define necessity differentlyClinical rationale must be documented

through coding.You cannot write more, to get paid

more.

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Determine Chief ComplaintDetermine Chief Complaint

The reason for the patient’s 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

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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services

Used for acute care visitsFive levels of serviceSeven components within the levels

– Key components – history, exam and medical decision making

– Contributory components – counseling, coordination of care, nature of presenting problem, and time

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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services

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

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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services

There are 5 Levels of service1. Minimal

2. Self-Limited or Minor

3. Low Severity

4. Moderate Severity

5. High Severity

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CPT Codes Used for E/M VisitsCPT Codes Used for E/M Visits

New Patients

Level 1 99201Level 2 99202Level 3 99203Level 4 99204Level 5 99205

Established Patients

99211 99212 99213 99214 99215

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Coding StepsCoding Steps

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Coding StepsCoding Steps

First Step - Determine if your patient is:

A New Patient or

An Established Patient

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Definition of a new patient:Definition of a new patient:

It is the patient’s first visit to the providerThe 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

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If your patient does not If your patient does not meet the definition of a meet the definition of a

New PatientNew Patient, , then they are an then they are an

Established PatientEstablished Patient

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Coding StepsCoding StepsSecond 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. Examination3. Medical Decision Making

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Coding StepsCoding Steps

New PatientsWithin the 3 key components, there are

5 levels of serviceRemember to Consider the Key

Components separately:– HPI, ROS, PFSH– Examination– Medical Decision Making

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Example - New PatientExample - New PatientThe Level of Service for a new patient visit is The Level of Service for a new patient visit is determined by the lowest level of service (1 determined by the lowest level of service (1

through 5) of the three key componentsthrough 5) of the three key components

HPI, ROS, PFSH 4

Examination 4

Medical Decision Making

3This is the lowest level

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Coding StepsCoding Steps

Established PatientsAgain 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

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Example – Established PatientExample – Established Patient

HPI, ROS, PFSH

3This is the middle level

EXAM 2

Medical Decision Making 4

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How to Steps of Coding: How to Steps of Coding: Determine Level of Medical Decision MakingDetermine Level of Medical Decision Making

Determine Level of History ComponentDetermine Level of History ComponentDetermine Level of Physical ExaminationDetermine Level of Physical Examination

(You will need to reference the chart – examination notes for this)(You will need to reference the chart – examination notes for this)

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Determine Level of Medical Determine Level of Medical Decision MakingDecision 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

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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section I: Section I: Diagnosis or Management of ProblemsDiagnosis or Management of Problems

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215One self-limited or minor problem

Two or more self-limited or minor problemsOne stable chronic conditionAcute uncomplicated illness

One or more chronic illnesses with complications

Two or more stable chronic conditionsUndiagnosed new problem w/uncertain prognoses

Acute illness with systemic symptomsAcute complicated injury

One or more chronic illness with severe complicationsAcute or chronic illness or injury that is life or limb threateningAbrupt change in neurologic status

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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section II: Diagnostic ProceduresSection II: Diagnostic Procedures

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

LabX-rayEKGUAUltrasound, etc.VenipunctureKOH

Physiologic tests not under stressPulmonary FunctionBarium EnemaArterial punctureSkin biopsies

Physiologic tests under stress-cardiac stress testsDiagnostic endoscopies with no risk factorsDeep needle or incisional biopsyObtained fluid from bodyCardiovascular imaging with contrast

Cardiovascular imaging with contrastInvasive diagnostic testsCardiac Electrophysiological tests Diagnostic endoscopies with identified risk factorsDiscography

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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section III: Section III: Treatment or Management OptionsTreatment or Management Options

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

RestGarglesElastic bandagesDressings

OTCsMinor surgeryPTOTIVs without additives

Minor surgery with risk factorsElective major surgery—no risk factors

Prescription drug managementIV fluids with additivesClosed facture or dislocation treatment w/o manipulationTherapeutic nuclear medicine

Elective Surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug treatment requiring intensive monitoringDecision not to resuscitate or de-escalate care because of poor prognosis

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How to Steps of Coding: How to Steps of Coding: Determine Level of History Component 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)

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Determine Level of History ComponentDetermine Level of History Component

Section I: History of Present IllnessSection I: History of Present Illness Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

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Determine Level of History ComponentDetermine Level of History Component

Section II: Review of SystemsSection 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

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Determine Level of History ComponentDetermine Level of History Component Section III: Patient, Family and Social HistorySection III: Patient, Family and Social History

Past medical history

– Medication allergies Patient’s family history Patient’s social history

– Age-appropriate review of past and current activities

Tobacco usage

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History Component MatrixHistory Component Matrix(Number of components of each HPI, (Number of components of each HPI, ROS & PFSH required for each level)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

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How to of Coding Steps: How to of Coding Steps: Determine Level of Physical ExaminationDetermine Level of Physical Examination

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

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Determine Level of Physical Examination:Determine Level of Physical Examination:# of body systems required for each level# 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

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Coding Matrix Example:Coding Matrix Example:

New Patient Established Patient

History 3 3

Exam 2 2

Medical Decision Making

3 3

Level of Coding 2 3

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Coding Matrix Example:Coding Matrix Example:

New Patient Established Patient

History 4 4

Exam 2 2

Medical Decision Making

4 4

Level of Coding 2 4

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Coding ExerciseCoding Exercise

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Coding Exercise for Evaluation/ Coding Exercise for Evaluation/ Management ServicesManagement 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 onlyhelped a little. She is a new patient. Document on the exam and encounter form to a level 3, using audit sheet as reference.

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How to Verify this is correct How to Verify this is correct level of documentation to level of documentation to

support level 3support level 3

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Count the componentsCount the components

HRI 1 - MidolHRI 1 - Midol

ROS 1 - crampsROS 1 - cramps

PFSH - 0PFSH - 0

______________________

Level 3Level 3

Exam 1-constExam 1-const

2-Abd2-Abd

3-back3-back

4-genito4-genito

________________________

Level 3Level 3

Med DecisionMed Decision

- acute/uncomp- acute/uncomp

- OTCs- OTCs

______________________

Level 3Level 3

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Counseling /Education OnlyCounseling /Education OnlyDuring and E and M VisitDuring and E and M Visit

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CPT Codes Used for CPT Codes Used for Counseling/Education Only Counseling/Education Only E and M VisitsE and M Visits

New Patients

10 minutes 9920120 minutes 9920230 minutes 9920345 minutes 9920460 minutes 99205

Established Patients

5 minutes 99211 10 minutes 99212 15 minutes 99213 25 minutes 99214 40 minutes 99215

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Preventive ServicesPreventive Services

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Preventive ServicesPreventive 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.

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Preventive ServicesPreventive Services

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

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Preventive Service CodesPreventive Service Codes

Age New Established< 1 99381 993911-4 99382 993925-11 99383 9939312-17 99384 9939418-39 99385 9939540-64 99387 9939765+ 99387 99397

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Preventive ServicesPreventive Services

Appropriate ICD-9 codes would be:

V20.2 for a Routine Infant or Child Health Check

V70.3 for a Sports Physical

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Preventive ServicesPreventive Services

Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately:– Examples:

Snellen TestLaboratory ImmunizationsAdministration of Immunizations

Coverage IssuesCoverage Issues

A provider should know what services are covered.

Services must be documented and medically necessary in order for payment to be made.

Do you, as a provider, know if all services provided are covered?

Are you documenting properly, and what about this “medically necessary” bit?

How Much are you Paid?How Much are you Paid?Reimbursement

– Reductions in reimbursement rates by provider type

Physician - not discountedNP or PA - sometimes discounted Clinical Psychologist - discountedLCSW - further discountedOther - discounted if

covered

Reimbursement IssuesReimbursement Issues

E&M codes are limited to physicians, PAs, NPs, nurses

Same is true for 90805, 90807, 90809 codes

An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs

Documentation and Coding:Documentation and Coding:Fraud and AbuseFraud and Abuse

Services MUST be medically necessary (determined by payers based on a review of services billed)

Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.

Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider

Elements of “Incident To”Elements of “Incident To”

An integral part of the physician’s professional service

Commonly rendered without charge or generally not itemized separately in the physician’s bill

Of a type that are commonly furnished in physician’s office or clinic

Furnished under the physician’s direct personal supervision

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Common Pitfalls inCommon Pitfalls inCodingCoding

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About Time With the PatientAbout 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

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Sports PhysicalsSports Physicals

They are not meant to be comprehensive physicals – their focus is different

Check www.aap.org for an appropriate form

You can bill for a complete PE and a sports PE within the same year

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Counseling VisitsCounseling Visits

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

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ExampleExampleDietary Surveillance & CounselingDietary Surveillance & Counseling

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

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Be Specific with the Be Specific with the codes you usecodes you use

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Coding Compliance Coding Compliance Audit Audit

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Questions & AnswersQuestions & Answers