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Coding for Local Health Department Clinic & School Sites

July 18, 2013

Presented by: Cynthia H. RobinsonInternal Policy Analyst III

1Table of ContentsCoding on the PEFDetermination of New or Established PatientsCoding of Preventive VisitsComponents for coding Other than Preventive E/M Visits Problem VisitsCoding of Problem Visits-New PatientsCoding of Problem Visits-Established PatientsMultiple Visits for the Same Patient on the Same Day2

This presentation was done to aid employees of health department clinics in coding and reporting of services. It could not possibly cover all of the circumstances which occur in these clinics on a day to day basis. This presentation is intended to assist in the training of new employees and to refresh existing employees.

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3Guiding PrinciplesOnly provide the level of care that is medically necessary per clinical judgment. Always provide and document services in accordance with the Core Clinical Service Guidelines (CCSG) and with established best practices. Always code and document exactly what care was provided.

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Coding on the Patient Encounter Form (PEF)5

6Coding on the PEFThe state-updated CH-45 (PEF) is used in most health department clinics. Some health departments prefer to create and use an abbreviated PEF at off site clinics (e.g. Flu Clinics & School sites). This is entirely permissible. Health Departments using their own forms are responsible for keeping these forms up-to-date.

Codes7Current Procedural Terminology (CPT) A set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers.CPT codes describe WHAT was done for the patient.International Classification of Disease 9th Revision 2009 (ICD-9) This system is required for reporting diagnoses and diseases to all U.S. Public Health Service and Department of Health and Human Services Programs, such as Medicare and Medicaid. ICD-9 codes describe WHY it was done.

8Examples of CodesCLINIC SETTING: 99211 Office or other outpatient visit for the evaluation and management of an established patient that may or may not require the presence of a physician.99393 Periodic comprehensive preventive medicine reevaluation & management of an individual late childhood (age 5 through 11 years)V741 Special Screening Examination for Pulmonary Tuberculosis / Z11.1-Encounter for screening for respiratory tuberculosisV202 - Routine Infant Or Child Health check/ Z00.129-Encounter for routine child health examination without abnormal findings

CPT codes - WHATICD-9/ICD-10 codes - WHY

9Coding E/M visits in health department clinics consists of: Preventive Visits E/M visits (e.g. well child exam, well woman checks)Evaluation/Management visits, which LHDs commonly refer to as problem visits (e.g. supply visits, STDs, cancer screenings)Coding E/M visits on the PEF

10Preventive Visits (e.g. Well Child Exams)Top left corner of PEF

Coding on the PEF

Other E/M Visits (Problem Visits)Top right corner of PEF

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Coding on the PEF

12REMEMBER: 992 codes - for use by physicians and mid level providers onlyW92 codes - for use by nurses (RNs)

Coding on the PEF Provider Level Physicians and mid level providers code in the upper portion of the Preventive and Other Than Preventive Sections.

Nurses code in the lower portion of the Preventive and Other Than Preventive Sections.

13Coding on the PEF- CPT codesCPT codes for lab tests, etc. that are done as part of the visit must be....Checked in the appropriatebox on the PEF

OR, if the service is not listed on the PEF it should be written in the area provided on the back of the PEF

Coding on the PEF - ICD codesICD codes need to be written on the PEF in the section that corresponds with the service that was provided.ICD codes will reflect why the patient presented. They are assigned based on the presenting problem(s) of the patient. REMEMBER: ICD codes for LHDs must be five digits. If the code is 3 or 4 digits, add dashes to make the code 5 digits long. ICD-10 will have 3-7 characters.14

Coding on the PEF - ICD codesThere is a box for a primary (P) ICD and a secondary (S) if needed. For example...a 4 y/o established patient, receives preventive exam by a nurse (V202-/Z00.129) and also receives vaccines (V069-/Z23).This would be coded on the preventive side of the PEF15

V069/Z23V202/Z00.129

16ICD Codes In Health Department SitesICD codes are revised annually and are effective on October 1 of each year.ICD9 is changing to ICD10 effective October 1, 2014. Many LHDs create their own listing of most commonly used ICD codes. REMEMBER: These lists must be updated annually.

Determination of New or Established Patients 17

18New & Established Patients

The Patient Encounter Form (PEF or CH-45) distinguishes between New Patients and Established Patients:

New Patients visits are coded in the areas highlighted in PINK.

Established Patients visits are coded in the areas highlighted in BLUE.

1818New & Established PatientsNEW PATIENT - a patient who has not received a professional service (i.e., preventive, problem focused, or procedure) at any health department or satellite clinic in the COUNTY within the past three years.Determination of new or established status is made on a COUNTY basis, not a district basis. 19

New & Established PatientsThe CMS (Clinic Management System) determines whether the patient is new or established at computer registration when the PEF label is created.The computerized registration process is generally not done at the satellite site itself, often making it difficult for the provider to know whether the patient is new or established.

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New & Established PatientsIf the provider cannot determine whether the patient is new or established by looking at the medical record, the provider should check the appropriate new patient level of visit and the appropriate established patient level of visit on the PEF. (See examples on next two slides.)This will save time for the provider and for staff doing the data entry. The PEF will not need to be sent back to the nurse for determination of level of visit. 21

New & Established PatientsClinic Setting: If the system is down or off-sitePatient presents to nurse requesting pregnancy test:

Staff doing data entry should look at label to determine if it is a new patient or established, then...Enter correct office visitMark through other visit22

V7241

New & Established PatientsUnder NO circumstances should staff entering data change the level of visit to accommodate a new or established patient status (unless that level was also marked on the PEF, as discussed in the previous slides). The provider must determine the level of visit. 23

Coding of Preventive Visits24

Coding of Preventive VisitsPreventive visits are reported when the patient receives a full preventive physical exam per the guidelines in the Core Clinical Service Guidelines (CCSG).Coding of these visits require three components: New or established patient statusAge of patient Completion of physical exam by protocols which are listed in the CCSG25

Components for coding Other than Preventive E/M Visits26Commonly Referred to as Problem Visits in Health Department Settings

Components of Problem VisitsProblem Visits are made up of three components which are directly linked to the coding of these services.History-consists of a combination of three parts:History of present illnessReview of systemsPast, family and social historyExamDecision makingThese three components are the driving forces behind the coding of Problem Visits.Understanding these three components is extremely important in accurate coding of problem visits.27

HistorySubjective documentation that is reported by the patient. Comparable to the S (subjective) portion of the SOAP noteCombination of three components History of present illness what the patient reports as problems, symptoms, time frames, etc.Review of systems what body systems are affected by the presenting problemsPast, family and social history what past, familial or social influences there might be on the seriousness and resolution of the problem 28

ExamObjective what the provider notes when assessing the patientThe exam is comparable to the O (objective) portion of the SOAP noteThe exam portion will be discussed in detail in the Coding of Problem Visits - New Patients section of this presentation

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Decision MakingThe decision making component consists of three parts...Presenting problem management optionsComparable to the A (assessment) portion of a SOAP note.After looking at the patient history and performing exam as needed, the assessment of what the patients problem(s) are

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Diagnostic procedures ordered Provider must decide what, if any, diagnostic procedures should be doneManagement options selectedWhat treatment the patient should receiveThe last two parts combined are comparable to the P (plan) portion of a SOAP note31Decision Making

Coding of Problem Visits

32New Patients

American Medical Association (AMA) rules require that you have documented some of each of these components for new patients: History Exam Decision makingThe AMA rules state that you must code Other E/M Office Visits for new patients to the lowest of these three components. By lowest of these three components, they mean the component which has the least impact on the visit.Should you be missing one of the three components on a new patient, an 80000 code will have to be used. This code gives you no reimbursement and no Work Resource Based Relative Values. So the time spent with this patient will be as though it never happened.33Coding of Problem Visits New Patients

The exam component will be the lowest of the three components 99% of the time. New patients should be coded by the amount of exam performed (which are commonly referred to as exam bullets because this is how they are identified in CPT classification).34Coding of Problem Visits New Patients

35Exam New PatientsA complete list of exam bullets can be found in the 1997 Documentation Guidelines for Evaluation & Management Services (developed jointly by the AMA & HCFA).

Exam New Patients CLINICThe five most common bullets are:General Appearance/Nutritional Status. (Although these appear on two lines of the HP/CH-13 and HP/CH-14 exam forms, they only count as one bullet.)Mood and AffectOrientationSkin (2 bullets possible) Inspection looking (e.g. pink, tan, intact)Palpation - touching (e.g. warm, dry)Vital signs can be used as an exam bullet also, but three vital signs from the following list MUST be done for it to count as a bullet:Sitting or standing blood pressure Supine blood pressureHeightWeightTemperaturePulseRespiration36

Following is a list of the number of exam bullets that corresponds to the level of office visit to code for new patients:1 to 5 exam bullets = 99201 or W9201 Brief6 to 11 exam bullets = 99202 or W9202 Expanded 12 to 17 exam bullets = 99203 or W9203 Detailed18 to 23 exam bullets = 99204 or W9204 Comprehensive A comprehensive office visit has the same requirements as full preventive visit (per the preventive guidelines in the CCSG). If this level of exam is performed, the provider should look at coding a full preventive exam on the patient.24 or more bullets = 99205 or W9205 Complex Comprehensive and Complex levels of new patient visits should seldom occur in a health department site. These have been addressed here in case of rare emergencies.37Coding of Problem Visits New Patients - CLINIC

38Coding of Problem Visits New Patients - CLINICThe AMA expects medical providers to do a more thorough exam, within reason, on a new patient to provide a good base line for future visits (see 907 KAR 3:130).

Remember to have some History, some decision making, however the Coding for new patients is directly related to the amount of exam bullets performed, as its usually the lowest component in HD.Count the number of exam bullets and code accordingly.39Coding of Problem Visits New Patients - CLINIC

Coding of Problem Visits New Patients - SCHOOLAccording to the new Coding Criteria for Coordinated School Health: Registered Nurses or other health dept. personnel may only code:W9201 & W9202

Count the amount of Exam Bullets provided as medically necessary and code one of the two permissible billable codes listed above 40Coding of Problem Visits

Established Patients41

To code a Problem Visit for an established patient, the AMA requires that only two of the three components be documented.History Exam Decision makingThe visit should be coded by the lowest of the two components.42Coding of Problem Visits Established Patients

The level of visit chosen for established patients will be driven by the lowest of either the history component or the medical decision making component. Exam performed should be what is required by protocol and medically necessary.43Coding of Problem Visits Established Patients

Coding of Problem Visits Established Patients (Clinic) 99211 and W9211 Brief No history is taken Decision making is minimal No ROS (review of systems)Examples:Negative TB skin test reading (NEVER write a SOAP note for a negative TB skin test reading. That raises the level of visit and is never medically necessary.)

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Coding of Problem Visits Established Patients (Clinic)99212 or W9212 LimitedRequires at least 2 of these 3 key components; Problem focused history;Straight forward decision making;Problem focused examPatients who have one or more self-limited or minor problem(s)ExamplesSupply Visit (no complaints or problems)STD Visit (no problems or negative results)Head lice (either suspected or found)

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Coding of Problem Visits Established Patients (Clinic)99213 or W9213 ExpandedRequires at least 2 of these 3 key components; Expanded problem focused history;Expanded problem focused examination;Decision making of low to moderate complexityExamplesPt to receive depo wt gain 5 lb since last visit, c/o occasional headachescounseled &depo adm.Positive TB skin test readingPositive STD visit with treatment

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Coding of Problem Visits Established Patients (Clinic)99214 or W9214 DetailedRequires at least 2 of these 3 key components; Detailed history;Detailed examination;Decision making of moderate complexityPresenting problems are of moderate to high complexity ExamplesTrue contraindication to contraceptive methodsOCs - B/P 160/92, c/o severe HAs daily with visual impairment - no contraceptive given until patient is further evaluated Patients presenting with problems significant enough that more case management is necessaryPt with abnormal breast exam *******Please keep in mind:907 KAR 3:010 Section 4PHYSICIANS MEDICAID only pays Doctors for TWO 99214 visits every 12 months

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Coding of Problem Visits Established Patients (Clinic)99214 or W9214 DetailedRequires at least 2 of these 3 key components; Detailed history;Detailed examination;Decision making of moderate complexityPresenting problems are of moderate to high complexity Example: Positive Preg test initial PN Visit -HIGH RISK PREGNANCY - includes 2 or More RISK FactorsSee below for RISK Factor examples: - History of Miscarriage/High Blood Pressure/Early labor - Preeclampsia - STI with pregnancy- Smoker - Obesity - Age (under or over)48

Coding of Problem Visits Established Patients (Clinic)99215 or W9215 ComprehensiveRequires at least 2 of these 3 key components: Comprehensive history;Comprehensive examination;Decision making of high complexityPresenting problems are of moderate to high complexitySignificant risk to the life of the patientExamplesHIV RapeAbrupt neurological changesAnaphylactic reaction to vaccineEmergency treatment necessary via EMS*******Please keep in mind:907 KAR 3:010 Section 4PHYSICIANS MEDICAID only pays Doctors for TWO 99215 visits every12 months

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Coding of Problem Visits Established Patients (School) 99211 and W9211 Brief No history is taken Decision making is minimal/ low severity/acuity No ROS (review of systems)Patients who have simple self-limited or minor problem(s) according to Coding Criteria for Coordinated School HealthExamples: Vomiting/diarrhea / Upper respiratory symptoms / Headache / Sprain / Strain / Bites / Blood Glucose with carb counting / Seizure disorder / Asthma / Allergies / Sterile dressing and soaks / Collecting and/or performance of tests blood glucose, urine glucose, pregnancy testing /

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Coding of Problem Visits Established Patients (School)99212 or W9212 LimitedRequires at least 2 of these 3 key components; Problem focused history;Straight forward decision making; complex severity/acuityProblem focused exam;Patients who have more complex self-limited or minor problem(s) according to Coding Criteria for Coordinated School HealthExamples: Vomiting/diarrhea / Upper respiratory symptoms / Headache / Sprain / Strain / Bites / Diabetes / Seizure disorder / Asthma / Allergies / Sterile dressing and soaks / Follow-up for acute illnesses and injuries

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Multiple Visits for the Same Patient on the Same Day52

A 25 modifier may be reported with a Preventive visit, if there is a significant enough and separately identifiable problem . The 25 modifier would be listed with problem-focused E/M visit.When immunizations are given, problem-focused E/M with a 25 modifier may be reported if there is a distinct and separately, identifiable reason for the E/M visit (i.e., a different diagnosis code).When an E/M is reported on the same day as another procedure , such as a MNT; the E/M will require a 25 modifier and the diagnosis code for the E/M needs to different from the diagnosis code for the MNT.

53The 25 modifier is located beneath the Other Than Preventive codes section. You may either check or circle the 25. Multiple Visits for the Same Patient on the Same Day with Different Problem (Clinic)OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVELCPT NEW Visit TypeCPT EST. Visit TypePROVIDER99201 Brief99211 Brief99202 Expanded99212 Limited99203 Detailed99213 Expanded99204 Comprehensive99214 DetailedICD (P)99205 Complex99215 Comprehensive 25 MODIFIER Separate E/M by same provider/same day NURSEICD (S)W9201 BriefW9211 BriefW9202 ExpandedW9212 LimitedW9203 DetailedW9213 ExpandedREF/DISPW9204 ComprehensiveW9214 DetailedW9205 ComplexW9215 Comprehensive

Example of when to use the 25 Modifier: (Clinic)39 year old established pt comes in for Family Planning preventive visit, while doing this pts family planning preventive visit, the APRN finds vaginal warts, and with the permission of the pt, treats.Coding would consist of: 993959921325 54

Another Example of when to use the 25 Modifier: (Clinic)17 year old established pt comes in for family planning supplies and RN finds out she has not received the Gardasil vaccine. Pt wants to receive this vaccine and is counseled per component. Coding would consist of: W921225 90460 90649

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PEF Changes for 201390718 - TD has been deleted, Due to all vaccines being preservative free. 90714 is the correct CPT Code to use for TD

J1055-Depo was Deleted, and replaced with J1050-Depo. 56

PEF Changes for 2013Lab CPT Codes added to the PEF, for easier access:

86780 x 2units Syphilis testing, if positive on VDRL state lab will inform LHD of this testing.86803 Hepatitis C Antibody

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Guiding PrinciplesOnly provide the level of care that is medically necessary. Always provide and document services in accordance with the Core Clinical Service Guidelines (CCSG) and with established best practices. Always code and document exactly what care was provided.

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References:Current Procedural Terminology 2013 International Classification of Disease 9th Revision 2012 1995 CMS document: Documentation Guidelines to Evaluation & Management Services1997 CMS document: Documentation Guidelines to Evaluation & Management ServicesCMS Evaluation & Management Service GuideDPH Policy: Coding Criteria for Coordinated School Health

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Recent CDP System Updates by: Sharon Trivette/Nellie Ramsey(6/3/2013) Claim Processor was updated to allow the coding and billing of:NDC dataCPT Modifier updated Four (4) modifiers can be submitted on a claimModifier override with letter MExtra modifiers required by different payers can be entered in override area per CPT code.Prior Authorization Code APrior Authorization numbers are entered with A and the number in override area.

60National Drug CodeThis is a National Requirement and the claim will deny without it. It is used with most injectable/implantable drugs such as DEPO, Rocephin and Mirena IUD. Vaccines are NOT included at this time.Must be 11 characters submitted in 5-4-2 formatIf not 11 characters, then populate with leading zerosXXXX-XXXX-XX=0XXXX-XXXX-XXXXXXX-XXX-XX=XXXXX-0XXX-XXXXXXX-XXXX-X=XXXXX-XXXX-0X

NDC

NDC PEF EntryThe nurse should indicate the NDC on the vial including the dashes. If the number is missing a digit of the format, insert the leading zero in the appropriate space.Support Staff will enter the 11 digit NDC number in the Override Area preceded with the letter F with no dashes.Example: vial says 0009-0746-30Nurse inserts leading zero 00009-0746-30Support Staff enters F00009074630 in override

Questions:Email: Localhealth.helpdesk@ky.gov

Phone: 502-564-6663 Option 1

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