Coding 2010 ASTHMA Coding 2010 ASTHMA Richard H. Tuck, MD, FAAP.

Coding 2010Coding 2010ASTHMAASTHMA

Richard H. Tuck, MD, FAAPRichard H. Tuck, MD, FAAP

Richard Tuck

Using and Reporting ICD-9-CM CodesUsing and Reporting ICD-9-CM Codes

Code to the highest degree of certainty for the encounter such assymptoms, signs, abnormal test results,

Probable, suspected ,questionable, or rule out should not be coded

List the ICD-9-CM code that is identified as the main reason forthe service first. Next list any current coexisting conditions.

Chronic disease treated on an ongoing basis may be coded

Asthma ICD CodingAsthma ICD Coding

Not consistent with current asthma diagnostic Not consistent with current asthma diagnostic criteria in ICD-9criteria in ICD-9

Will be revised to meet diagnostic criteria in Will be revised to meet diagnostic criteria in ICD-10ICD-10

Code symptoms until confident of asthma Code symptoms until confident of asthma diagnosisdiagnosis

Asthma ICD CodingAsthma ICD CodingSymptomsSymptoms

465.9465.9 URIURI 466.0466.0 BronchitisBronchitis 466.19466.19 BronchiolitisBronchiolitis 486486 PneumoniaPneumonia 519.11519.11 Acute bronchospasmAcute bronchospasm 786.05786.05 Shortness of breathShortness of breath 786.06786.06 TachypneaTachypnea 786.07786.07 WheezingWheezing 786.2786.2 CoughCough

Asthma ICD CodingAsthma ICD CodingAsthma DiagnosisAsthma Diagnosis

Note fifth digit classificationNote fifth digit classification– 0 0 unspecifiedunspecified– 11 with status asthmaticuswith status asthmaticus– 22 with (acute) exacerbationwith (acute) exacerbation

493.x 493.x AsthmaAsthma

Asthma ICD CodingAsthma ICD CodingAsthma DiagnosisAsthma Diagnosis

493.0493.0 Extrinsic asthmaExtrinsic asthma– 493.00493.00 childhood w/o statuschildhood w/o status– 493.01493.01 childhood with exacerbationchildhood with exacerbation

493.1493.1 Intrinsic asthmaIntrinsic asthma 493.2493.2 Chronic obstructive asthmaChronic obstructive asthma 493.81493.81 Exercise induced asthmaExercise induced asthma 493.82493.82 Cough variant asthmaCough variant asthma 493.9493.9 Asthma unspecifiedAsthma unspecified

V - CodesV - Codes

V 65.11 V 65.11 Conference with Parent Conference with Parent V 65.5V 65.5 Feared Illness / None Found Feared Illness / None Found V 67.9V 67.9 Follow up Exam Follow up Exam V 67.59 Follow up after RxV 67.59 Follow up after Rx

TimeTime

An explicit factor to assist in selecting the most An explicit factor to assist in selecting the most appropriate level of E/M servicesappropriate level of E/M services

When counseling and/or coordination of care are When counseling and/or coordination of care are more than more than 50%50% of the face to face encounter, of the face to face encounter, then time is the key controlling factor.then time is the key controlling factor.

Utilize prolonged services codes (time based)Utilize prolonged services codes (time based)

**Documentation in the medical record is a mustDocumentation in the medical record is a must

Office Visits – New PatientOffice Visits – New Patient

CodesCodes 9920199201 9920299202 9920399203 9920499204 9920599205

HistoryHistory Problem Problem FocusedFocused

Expanded Expanded Problem Problem FocusedFocused

DetailedDetailed Compre Compre

hensivehensive

Compre Compre

hensivehensive

ExamExam Problem Problem FocusedFocused


DetailedDetailed CompreCompre

hensivehensive

CompreCompre

hensivehensive

Decision Decision MakingMaking

Straight Straight forwardforward


Low Low complexcomplex

Moderate Moderate complexcomplex

High High complexcomplex

Time FFTime FF 1010 2020 3030 4545 6060

Key #Key # 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3

Office Visits – Established PatientOffice Visits – Established PatientCodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215

HistoryHistory Not Not RequiredRequired

Problem Problem FocusedFocused


DetailedDetailed Compre Compre hensivehensive

ExamExam Not Not RequiredRequired



Detailed Detailed Compre Compre hensivehensive


Not Not RequiredRequired


Low Low ComplexComplex

Mod Mod ComplexComplex

High High ComplexComplex

Time FFTime FF 55 1010 1515 2525 4040


CodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215

HistoryHistory Not Not RequiredRequired




Required Required Elements Elements

HPI 1-3 HPI 1-3 ROS N/A ROS N/A PFSH N/APFSH N/A

HPI 1-3 HPI 1-3 ROS 1 ROS 1 PFSH PFSH N/AN/A

HPI 4+ HPI 4+ ROS 2-9 ROS 2-9 PFSH 1/3PFSH 1/3

HPI 4+HPI 4+ROS 10+ROS 10+PFSH 2/3 PFSH 2/3

ExamExam Not Not RequiredRequired




Required Required ElementsElements

1 Area 1 Area 2-4 Areas2-4 Areas 5-7 Areas5-7 Areas >8 Areas>8 Areas


Not Not RequiredRequired


Low Low ComplexComplex


High ComplexHigh Complex

Time FFTime FF 55 1010 1515 2525 4040


Asthma 99213 Asthma 99213 →→ 99214 99214 CSHCNCSHCN New DiagnosisNew Diagnosis Repeat visit – patient worseRepeat visit – patient worse ComorbiditiesComorbidities Lab or Xray ordered Lab or Xray ordered Consultation indicated Consultation indicated Prescription writtenPrescription written Office procedures required (aerosol, pulse ox)Office procedures required (aerosol, pulse ox) Chronic problem – exacerbation, changes in RxChronic problem – exacerbation, changes in Rx Time based problem/ “consultation”Time based problem/ “consultation”

Preventive Medicine ServicesPreventive Medicine Services

E/M services performed in the absence of a E/M services performed in the absence of a significant problem/abnormalitysignificant problem/abnormality

Extent and focus depends on the patient’s ageExtent and focus depends on the patient’s age Include counseling/anticipatory guidance/risk Include counseling/anticipatory guidance/risk

factor reductionfactor reduction Do not includeDo not include office procedures, ancillary office procedures, ancillary

services, and immunizationsservices, and immunizations


New PatientNew PatientInitial E/M of a new patient including Initial E/M of a new patient including an age and gender an age and gender appropriate history, examinationappropriate history, examination

identification of risk factors, ordering of appropriate identification of risk factors, ordering of appropriate tests, and counseling tests, and counseling RVU/ 2009 MedicareRVU/ 2009 Medicare

99381 99381 Age < 1 year Age < 1 year 2.51/ $ 90.532.51/ $ 90.5399382 99382 Ages 1 – 4 years Ages 1 – 4 years 2.73/ $ 98.462.73/ $ 98.469938399383 Ages 5 – 11 years Ages 5 – 11 years 2.71 /$ 97.742.71 /$ 97.7499384 99384 Ages 12 – 17 years Ages 12 – 17 years 2.95/ $106.402.95/ $106.4099385 99385 Ages 18 – 39 years Ages 18 – 39 years 2.95/ $106.402.95/ $106.40


Established PatientEstablished PatientPeriodic reevaluation and management requiring Periodic reevaluation and management requiring an age an age and gender appropriate history, examination and gender appropriate history, examination identification of risk factors, ordering of studies, and identification of risk factors, ordering of studies, and counseling counseling RVU/ 2009 MedicareRVU/ 2009 Medicare

9939199391 Age < 1 Age < 1 2.09/ $75.382.09/ $75.389939299392 Ages 1 – 4 years Ages 1 – 4 years 2.33/ $84.042.33/ $84.049939399393 Ages 5 – 11 years Ages 5 – 11 years 2.32 /$83.672.32 /$83.679939499394 Ages 12 – 17 years Ages 12 – 17 years 2.55/ $91.972.55/ $91.9799395 99395 Ages 18 – 39 years Ages 18 – 39 years 2.56/ $92.332.56/ $92.33

Preventive Medicine vs Preventive Medicine vs E/M Office Visit ?E/M Office Visit ?

How do you code for asthma management at the How do you code for asthma management at the time of a preventive medicine visit?time of a preventive medicine visit?

25 Modifier25 Modifier

If a If a significant significant problem/abnormality is found at a problem/abnormality is found at a preventive medicine visit:preventive medicine visit:– Code the appropriate E/M visit in addition to Code the appropriate E/M visit in addition to 99381 – 9939599381 – 99395- Add modifier Add modifier –25–25 to the E/M code to the E/M code- If not significant code only 99381 – 99395If not significant code only 99381 – 99395

- Option: Have patient return for a separate E/M Option: Have patient return for a separate E/M visit for asthma managementvisit for asthma management

Office proceduresOffice procedures

ImmunizationsImmunizations Minor proceduresMinor procedures Lab and x-ray servicesLab and x-ray services Medical servicesMedical services Screening proceduresScreening procedures Special servicesSpecial services

Vaccine Coding SpecificsVaccine Coding Specifics

Each vaccine has a specific Each vaccine has a specific CPTCPT code code AMA identifies vaccines pending FDA approval AMA identifies vaccines pending FDA approval

~ code assigned~ code assigned Each vaccine has an appropriate Each vaccine has an appropriate

ICD-9ICD-9 diagnosis code diagnosis code Each vaccine should be linked to an individual Each vaccine should be linked to an individual

IAIA (immunization administration) code (immunization administration) code

ImmunizationsImmunizations Bill and Document Bill and Document ALLALL::

– E/M VisitE/M Visit » Office Visit, Preventive MedicineOffice Visit, Preventive Medicine

– Immunization AdministrationImmunization Administration» 90471 – 9047490471 – 90474» 90465 - 90468 (2005 Peds specific)90465 - 90468 (2005 Peds specific)

– Vaccine/ToxoidVaccine/Toxoid» 90476 – 9074990476 – 90749

Link to ICD DiagnosesLink to ICD Diagnoses– V20.2 Well ChildV20.2 Well Child– Asthma diagnosisAsthma diagnosis– + Specific Vaccine V Codes+ Specific Vaccine V Codes

H1N1 Influenza CodingH1N1 Influenza Coding CPTCPT

– 9047090470 - H1N1 IA, any route, including counseling $24 - H1N1 IA, any route, including counseling $24– 90465-90468, 90471-90472 – if directed by plan90465-90468, 90471-90472 – if directed by plan– G9141G9141- H1N1 IA, any route, including counseling Ohio - H1N1 IA, any route, including counseling Ohio

Medicare $19.95Medicare $19.95 ICD ICD

– 9066390663 – Influenza vaccine, pandemic formulation – Influenza vaccine, pandemic formulation– G9142G9142 –Influenza A vaccine (H1N1), any route –Influenza A vaccine (H1N1), any route

administrationadministration– $0 vs. $0.01 charge$0 vs. $0.01 charge

H1N1 Influenza Testing CodingH1N1 Influenza Testing Coding

Rapid Influenza testingRapid Influenza testing– If testing for two distinct virus strains (A & B) If testing for two distinct virus strains (A & B)

Report test for rapid influenza test twice Report test for rapid influenza test twice 87804 87804 87804-59 (distinct procedure modifier)87804-59 (distinct procedure modifier)

Non Face-To-Face Physician Non Face-To-Face Physician ServicesServices

Telephone CallsTelephone Calls

Reviewing Records/ReportsReviewing Records/Reports

Completing FormsCompleting Forms

Managing, Modifying Care PlansManaging, Modifying Care Plans

Case ManagementCase Management

Telephone ServicesTelephone ServicesCPT 2008CPT 2008

9944199441 Physician to est patient, parent or Physician to est patient, parent or guardian guardian 2009 medicare2009 medicare 5 – 10 minutes of medical discussion 5 – 10 minutes of medical discussion ($12.62)($12.62) No related E/M service within No related E/M service within previous 7 days No related E/M service in next previous 7 days No related E/M service in next 24 hours or next 24 hours or next available appointmentavailable appointment

9944299442 11 – 20 minutes11 – 20 minutes ($24.89)($24.89) 9944399443 21 – 30 minutes21 – 30 minutes ($38.33)($38.33)

Non Face-to-Face Non-Physician ServicesNon Face-to-Face Non-Physician ServicesCPT 2008CPT 2008

Telephone – by qualified non-physician health care Telephone – by qualified non-physician health care professionalprofessional No related E/M service previous 7 days No No related E/M service previous 7 days No related other service in next 24 hours or related other service in next 24 hours or next next available appointment available appointment 2009 medicare2009 medicare

9896698966 5 – 10 minutes medical discussion 5 – 10 minutes medical discussion ($12.26)($12.26)

9896798967 11 – 20 minutes11 – 20 minutes ($24.89)($24.89)

9896898968 21 – 30 minutes 21 – 30 minutes ($37.15)($37.15)

Online Medical EvaluationOnline Medical EvaluationCPT 2008CPT 2008

9944499444 Online E/M service provided by a Online E/M service provided by a physician to an est patient, parent, guardian or physician to an est patient, parent, guardian or health care provider Not originating from related health care provider Not originating from related E/M service in previous 7 days E/M service in previous 7 days In response to patient’s online inquiry In response to patient’s online inquiry Using internet or similar communications Using internet or similar communications network Requires “timely response” network Requires “timely response”

Permanent storage of encounter Permanent storage of encounter ($0.00)($0.00)

Non Face-to-Face Non-physician ServicesNon Face-to-Face Non-physician ServicesCPT 2008CPT 2008

Online Medical EvaluationOnline Medical Evaluation 9896998969 Online assessment and management, Online assessment and management,

by non-physician health care professional by non-physician health care professional No related assessment and management service in No related assessment and management service in

previous 7 days previous 7 days Using internet or similar electronic communication Using internet or similar electronic communication

network network In response to patient’s on line inquiry In response to patient’s on line inquiry ($0.00)($0.00) Timely response with permanent storage of Timely response with permanent storage of encounterencounter

CSHCNCSHCNChildren with Special Health Care NeedsChildren with Special Health Care Needs

Case Management ServicesCase Management Services

Process in which a physician is responsible for Process in which a physician is responsible for direct care of a patient, and for coordinating and direct care of a patient, and for coordinating and supervising other health care services required .supervising other health care services required .

Case Management Services Case Management Services (new/revised)(new/revised)CPT 2008CPT 2008

Medical team conference (99366 – 99368) addedMedical team conference (99366 – 99368) added– 9936699366Direct ContactDirect Contact with Patient and/or Family, 30 with Patient and/or Family, 30

minutes or more, non physician participation Physician minutes or more, non physician participation Physician participation use E/M face to face servicesparticipation use E/M face to face services

– 9936799367W/O Direct ContactW/O Direct Contact (Patient and/or Family not (Patient and/or Family not present), 30 minutes or more, physician participationpresent), 30 minutes or more, physician participation

– 9936899368non physician participationnon physician participation 99361 – 9936299361 – 99362 DELETEDDELETED

Behavior Change InterventionBehavior Change Intervention

Screening Brief Interventions (SBIScreening Brief Interventions (SBI)) Behavior change services involve specific Behavior change services involve specific

validated interventionsvalidated interventions of assessing readiness for of assessing readiness for change and barriers to change, advising a change in change and barriers to change, advising a change in behavior, assisting by providing specific suggested behavior, assisting by providing specific suggested actions and motivational counseling, and arranging actions and motivational counseling, and arranging for services and follow-upfor services and follow-up

Examples: Tobacco and Drug/Alcohol SBIExamples: Tobacco and Drug/Alcohol SBI

Behavior Change InterventionBehavior Change InterventionCPT 2008CPT 2008

9940699406 Smoking and tobacco use cessation Smoking and tobacco use cessation counseling visit, 3 – 10 minutescounseling visit, 3 – 10 minutes ($12.98)($12.98)

9940799407 > 10 minutes> 10 minutes ($24.89)($24.89)

Behavior Change InterventionBehavior Change InterventionCPT 2008CPT 2008

Provided by : Physician or Provided by : Physician or “other qualified health care “other qualified health care professional”professional”

E/M Service provided same day must be distinct E/M Service provided same day must be distinct -25 modifier -25 modifier

Provide Consultations !Provide Consultations !99241-9924599241-99245

Payment is Payment is 25-42%25-42% higher than corresponding new higher than corresponding new patient office visit codes, and…patient office visit codes, and…

Documentation requirements for History, Exam, and Documentation requirements for History, Exam, and MDM are the same!MDM are the same!

Consult codes are problem-based and can be used for Consult codes are problem-based and can be used for new new oror established patients established patients

Consultations – Consultations – 5 5 R’s - 2008 R’s - 2008

REASON:REASON: Medically necessaryMedically necessary

REQUESTREQUEST: By another physician or other appropriate source: By another physician or other appropriate source

RENDERRENDER: May initiate diagnostic and/or therapeutic services: May initiate diagnostic and/or therapeutic services

REPORTREPORT: By written report back to the requesting source: By written report back to the requesting source

RETURNRETURN: : Patient back to requesting physician/source Patient back to requesting physician/source

Office Consultation/ New or EstOffice Consultation/ New or EstCode Code 9924199241 9924299242 9924399243 9924499244 9924599245

HistoryHistory Problem Problem FocusedFocused



Compre Compre hensivehensive

ExamExam Problem Problem FocusedFocused



Compre Compre hensivehensive


StraightfdStraightfd StraightfdStraightfd Low Low ComplexComplex


High High ComplexComplex

Time FFTime FF 1515 3030 4040 6060 8080

Key # Key # 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3

Prolonged ServicesProlonged Services(99354-99359)(99354-99359)

Code series defining prolonged services by:Code series defining prolonged services by:– Site of serviceSite of service– Direct or without Direct patient contactDirect or without Direct patient contact– TimeTime

Reported in addition to other physician service, Reported in addition to other physician service, including E/M services at any levelincluding E/M services at any level

Total time for a given date, even if the time is not Total time for a given date, even if the time is not continuouscontinuous

Time must be of 30 minutes or moreTime must be of 30 minutes or more

Prolonged ServicesProlonged ServicesDirect Patient Direct Patient CareCare

OutpatientOutpatient InpatientInpatient

Face to FaceFace to Face 9935499354 first hour first hour

> 30 min> 30 min

9935699356 first hour first hour

> 30 min > 30 min

Face to FaceFace to Face 99355 99355 each add 30 mineach add 30 min

> 75 min> 75 min

99357 99357 each add 30 mineach add 30 min

> 75 min> 75 min

Before or after Before or after Face to Face to FaceFace


> 30 min> 30 min


> 30 min> 30 min

Before or after Before or after Face to FaceFace to Face

9935999359 each add 30 mineach add 30 min

> 75 min> 75 min

9935999359 each add 30 mineach add 30 min

> 75 min> 75 min

CODE FOR CODE FOR

ASTHMA PROCEDURES !ASTHMA PROCEDURES !

Use HCPCS Codes for SuppliesUse HCPCS Codes for Supplies

If not included as standard practice expense for If not included as standard practice expense for the procedure the procedure (Practice expense component of RBRVS)(Practice expense component of RBRVS)

CPT 99070 CPT 99070 General Nonspecific code for suppliesGeneral Nonspecific code for supplies

HCPCS codes are preferable HCPCS codes are preferable AlphanumericAlphanumeric

HCPCS CodesHCPCS Codes

Used to report suppliesUsed to report supplies J1100 - Dexamethasone injection, 1 mgJ1100 - Dexamethasone injection, 1 mg J0170 - EpinephrineJ0170 - Epinephrine J0696 - Ceftriaxone, per 250 mgJ0696 - Ceftriaxone, per 250 mg J7613 - Albuterol for inhalation, 1 unit doseJ7613 - Albuterol for inhalation, 1 unit dose

Minor Office ProceduresMinor Office Procedures

CPTCPT RVU/ 2009 RVU/ 2009 MedicareMedicare

Aerosol Rx only Aerosol Rx only 94640 0.37/ $13.34 94640 0.37/ $13.34 (X-76 for multiple aerosols)(X-76 for multiple aerosols)

Allergy injection (#1)Allergy injection (#1) 9511595115 0.29/ 0.29/ $10.46$10.46

#2 or more#2 or more 9511795117 0.35/ $12.62 0.35/ $12.62

Injection / IV Hydration CodesInjection / IV Hydration Codes20092009

90772 90772 →→ 96372 96372 Therapeutic Injection, Sub Q or IMTherapeutic Injection, Sub Q or IM

9076090760 →→ 96360 96360 IV Infusion, hydration, initial 31 min IV Infusion, hydration, initial 31 min

to 1 hourto 1 hour 9076190761 →→ 96361 96361

IV Infusion, hydration, each add hourIV Infusion, hydration, each add hour

Special Services and ReportsSpecial Services and Reports“Modifier-Like” Codes“Modifier-Like” Codes

99050 99050 - Services provided in- Services provided in office other than office other than regularly regularly scheduled hours normally closedscheduled hours normally closed

9905199051 - Services provided in office during regularly - Services provided in office during regularly scheduled evening, weekend, holiday hours scheduled evening, weekend, holiday hours

9905399053 - Services provided 10PM to 8AM at 24 hour facility - Services provided 10PM to 8AM at 24 hour facility 9905899058 - Office services on an emergency basis - Office services on an emergency basis

Codes billed in addition to basic serviceCodes billed in addition to basic service

Optimizing Reimbursement Through Optimizing Reimbursement Through CPT CodingCPT Coding

Utilize TimeTime spent in counseling and coordination of care greater than 50% of the visit time

Ex: 99213 (15 min) to 99214 (25 min)Asthma requiring extensive counselingAsthma followup visit

Document time spent and counseling issues

Documentation/ ICD 9 CMDocumentation/ ICD 9 CM

ICD coding should support higher levels of ICD coding should support higher levels of coding (coding (medical necessitymedical necessity))

99213 to 9921499213 to 99214 Code multiple diagnosesCode multiple diagnoses Document chronic condition when an acute Document chronic condition when an acute

problem is presentedproblem is presented– AsthmaAsthma– HypoxiaHypoxia

Code for extensive medical servicesCode for extensive medical services

Optimize standard office visit servicesOptimize standard office visit services– Hx, PE, ComplexityHx, PE, Complexity– TimeTime

$ OV < Prev Med < Consultation$ OV < Prev Med < Consultation Utilize Utilize prolonged services codesprolonged services codes

– 99354-9935999354-99359 For excess time spent beyond E/M code For excess time spent beyond E/M code

DOCUMENT !DOCUMENT !



**

Turn to AAP for Help – Turn to AAP for Help – State AAP Pediatric Councils State AAP Pediatric Councils

SOAPMSOAPMaap.org PMOaap.org PMO

AAP Your CODING CONNECTION AAP Your CODING CONNECTION Coding & Reimbursement ResourcesCoding & Reimbursement Resources

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Coding publications: Coding for Pediatrics, Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, RBRVS Brochure, AAP NewsAAP News Coding Corner Coding Corner

Coding 2010 ASTHMA Coding 2010 ASTHMA Richard H. Tuck, MD, FAAP.

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Transcript of Coding 2010 ASTHMA Coding 2010 ASTHMA Richard H. Tuck, MD, FAAP.