Preventive Services Improvement Initiative

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					              Coding 101
   The Partnership TOT, September 22, 2008


Taken from “Beginning Coding”, “Intermediate
Coding”, and “I Hate Coding” by Dianne Demers
Welcome and Expectations




                           2
Objectives
   The 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            3
Coding Background and
     Terminology




                        4
Coding Definition


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




                                                   5
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)

                                                   6
Coding Is Not The
 Same As Billing




                    7
Coding is Medicare Drive

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




                                               8
SBHC 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.


                                             9
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
                                      10
The 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)


                                           11
  When a provider is under-
coding 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.

                                        12
 There Are Two Coding
Guidelines - 1995 & 1997
 Both 1995 and 1997 guidelines are
  approved for use by CMS
 Agencies may specify use of 1995 or
  1997 guidelines
 1997 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
                                           13
Coding Guidelines
1995 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/Download
 s/1995dg.pdf

                                            14
Fraud
     Intentional deception or
      misrepresentation
      ● Deliberately billing for services not
        performed
      ● Unbundling of services
      ● Intentionally submitting duplicate claims




                                                    15
Abuse
     Improper billing practices
      ● Billing for non-covered services
      ● Misusing codes on a claim form




                                           16
Errors
      Accept it, you will
       make them.
      Your best defense
       is having a plan for
       your coding and
       being able to
       explain it.



                              17
Coding Does Not
  Equal Good
    Medicine




                  18
But - Coding is Good
  Documentation




                       19
CPT Codes document:

     Level of Service

     Procedures Provided




                            20
Examples of CPT codes

  Evaluation   Preventive
     &         Health
Management     99391
    99211      99392
    99212      99393
    99213      99394
    99214      99395
               99397
    99215
               99397        21
ICD-9 and DSM4 Codes
       document:

  The reason behind the visit

(They must support the CPT codes)




                                    22
General Coding Principles

    Coding gets you paid for your services
    Coding can be used to justify the need
     for services to your funders




                                              23
Coding 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 exists
          ● Use a 4-digit code only if there is no 5-
            digit code with the same category
          ● Use 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
                                                            24
ICD-9-CM Codes
 Range from 001.0 to V82.9
  They identify:
   ● Diagnoses
   ● Symptoms
   ● Conditions
   ● Problems
   ● Complaints
   ● Other reason for the procedure, service, or
    supply provided
                                                   25
ICD-9-CM Codes
    Three volumes
      ● Volume 1 Tabular List of Diseases
         ● Notes 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 Procedures
         ● Used almost exclusively for hospital
           services

 PS: (All 3 Volumes are generally found in one binding)
                                                          26
―V‖ 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
                                                       27
―V‖ Codes
      Can be used as a:
       ● Solo Code
       ● Principal code
       ● Secondary code


      May represent check-ups, screenings,
       administrative requests, prescription
       refills
                                               28
Rules for Coding
Outpatient Visits



                    29
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 Visits
     New Patients vs. Established Patients
                                              30
Determine Medical Necessity
   Services are reasonable and
    necessary for the diagnosis and
    treatment of illness or injury.
   All payors define necessity differently
   Clinical rationale must be documented
    through coding.
   You cannot write more, to get paid
    more.

                                              31
Determine 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



                                            32
Evaluation/Management
(E / M) Services
   Used for acute care visits
   Five levels of service
   Seven components within the levels
      ● Key components – history, exam and
        medical decision making
      ● Contributory components – counseling,
        coordination of care, nature of presenting
        problem, and time

                                                     33
Evaluation/Management
(E / M) Services
     Beginning information about coding
      deals with the three key components:
      ● History
      ● Examination
      ● Medical Decision Making




                                             34
Evaluation/Management
(E / M) Services
   There are 5 Levels of service
     1. Minimal
     2. Self-Limited or Minor
     3. Low Severity
     4. Moderate Severity
     5. High Severity



                                   35
CPT Codes Used for E/M Visits

       New Patients   Established Patients

  Level 1   99201       99211
  Level 2   99202       99212
  Level 3   99203       99213
  Level 4   99204       99214
  Level 5   99205       99215

                                             37
Coding Steps




               38
Coding Steps
     First Step - Determine if your patient is:

         A New Patient
              or
        An Established Patient



                                                   39
Definition of a new patient:
  It is the patient’s first visit to the provider
  The 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
                                                     40
If your patient does not
meet the definition of a
     New Patient,
    then they are an
Established Patient

                           41
Coding Steps
    Second 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. Examination
     3. Medical Decision Making
                                                 42
Coding Steps
New Patients
 Within the 3 key components, there are
  5 levels of service
 Remember to Consider the Key
  Components separately:
    ● HPI, ROS, PFSH
    ● Examination
    ● Medical Decision Making


                                           43
 Example - New Patient
 The Level of Service for a new patient visit is
 determined by the lowest level of service (1
 through 5) of the three key components



HPI, ROS, PFSH                         4

Examination                          4
                                     3
Medical Decision Making This is the lowest level
                                                   44
Coding Steps
Established Patients
   Again 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                              45
Example – Established Patient
                                      3
HPI, ROS, PFSH            This is the middle level


EXAM                                 2


Medical Decision Making              4


                                                     46
Why is this?



               47
      Answer . . .
   There has to be a
system, and this is what
  AMA came up with.


                           48
Coding Jeopardy/
  Match Game



                   49
How to Steps of Coding




                         50
   How to Steps of Coding:
Determine Level of Medical Decision Making
  Determine Level of History Component
 Determine Level of Physical Examination

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




                                                                         51
Determine Level of Medical
     Decision 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

                                               52
Determine Level of Medical Decision Making
Section I: Diagnosis or Management of Problems

  99201    99202          99203                   99204                99205
  99211    99212          99213                   99214                99215
          One self-    Two or more self-    One or more chronic   One or more chronic
          limited or   limited or minor     illnesses with        illness with severe
          minor        problems             complications         complications
          problem      One stable chronic   Two or more stable    Acute or chronic
                       condition            chronic conditions    illness or injury that
                       Acute                                      is life or limb
                                            Undiagnosed new       threatening
                       uncomplicated        problem w/uncertain
                       illness              prognoses             Abrupt change in
                                                                  neurologic status
                                            Acute illness with
                                            systemic
                                            symptoms
                                            Acute complicated
                                            injury

                                                                                           53
Determine Level of Medical Decision Making
Section II: Diagnostic Procedures
 99201   99202          99203               99204                  99205
 99211   99212          99213               99214                  99215
         Lab            Physiologic tests   Physiologic tests      Cardiovascular
                        not under stress    under stress-          imaging with contrast
         X-ray                              cardiac stress tests
                        Pulmonary                                  Invasive diagnostic
         EKG            Function            Diagnostic             tests
         UA             Barium Enema        endoscopies with       Cardiac
                                            no risk factors        Electrophysiological
         Ultrasound,    Arterial puncture
         etc.           Skin biopsies       Deep needle or         tests Diagnostic
                                            incisional biopsy      endoscopies with
         Venipuncture                       Obtained fluid from    identified risk factors
         KOH                                body                   Discography
                                            Cardiovascular
                                            imaging with
                                            contrast




                                                                                             54
Determine Level of Medical Decision Making
Section III: Treatment or Management Options
99201     99202          99203                99204                      99205
99211     99212          99213                99214                      99215
        Rest        OTCs            Minor surgery with risk     Elective Surgery with
        Gargles     Minor surgery   factors                     identified risk factors
        Elastic     PT              Elective major surgery—     Emergency major
        bandages    OT              no risk factors             surgery
        Dressings   IVs without     Prescription drug           Parenteral controlled
                    additives       management                  substances
                                    IV fluids with additives    Drug treatment
                                                                requiring intensive
                                    Closed facture or           monitoring
                                    dislocation treatment w/o
                                    manipulation                Decision not to
                                                                resuscitate or de-
                                    Therapeutic nuclear         escalate care because
                                    medicine                    of poor prognosis




                                                                                          55
How to Steps of Coding:
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)




                                                      56
Determine Level of History Component
Section I: History of Present Illness

        Location
        Quality
        Severity
        Duration
        Timing
        Context
        Modifying factors
        Associated signs and symptoms

                                         57
Determine Level of History Component
Section 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
                                                         58
Determine Level of History Component
Section 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


                                                  59
 History Component Matrix
 (Number of components of each HPI,
 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

                                                  60
How to of Coding Steps:
Determine Level of Physical Examination
       Constitutional
       Eyes
       Ears, Nose, Mouth, Throat
       Cardiovascular
       Respiratory
       Gastrointestinal
       Genitourinary
       Musculoskletal
       Skin
       Neurologic
       Psychiatric
       Hematologic/Lympatic/Immunologic


                                           61
Determine Level of Physical Examination:
# 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




                                                62
Coding Matrix Example:

                   New Patient   Established
                                   Patient
 History                3             3
 Exam                   2            2
 Medical                3            3
 Decision
 Making
 Level of Coding        2            3
                                               63
Coding Matrix Example:
                   New Patient Established
                                 Patient
History                4            4
Exam                   2            2
Medical Decision       4            4
Making
Level of Coding        2            4

                                             64
Coding Exercise




                  65
Coding Exercise for Evaluation/
    Management 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 only
 helped a little. She is a new patient.
 Document on the exam and encounter
 form to a level 3, using audit sheet
 as reference.

                                              66
67
68
How to Verify this is correct
 level of documentation to
       support level 3




                                69
70
       Count the components

HRI 1 - Midol    Exam 1-const         Med Decision
ROS 1 - cramps        2-Abd           - acute/uncomp
PFSH - 0               3-back         - OTCs
                           4-genito
___________      ____________         ___________
Level 3          Level 3              Level 3

                                                       71
72
Preventive Services




                      73
Preventive 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.

                                           74
Preventive Services
   ―Comprehensive‖ in a preventive
    service examination is not synonymous
    with a ―comprehensive‖ E/M
    examination.




                                            75
Preventive Service Codes

  Age      New    Established
  <1      99381     99391
  1-4     99382     99392
  5-11    99383     99393
 12-17    99384     99394
 18-39    99385     99395
 40-64    99387     99397
  65+     99387     99397
                                76
Preventive Services

   Appropriate ICD-9 codes would be:

      V20.2 for a Routine Infant or Child Health
       Check

      V70.3 for a Sports Physical



                                                    77
Preventive Services
    Additional services provided at the time
     of the visit should be reported with their
     specific CPT codes listed separately:
     ● Examples:
        ● Snellen Test
        ● Laboratory
        ● Immunizations
        ● Administration of Immunizations



                                                  78
Mental Health Services




                         79
How do you document mental
health services?
   Who documents mental health
    services?
   Where are mental health services
    documented?
      ● (mental health chart, medical record,
        both charts, log sheet, database,
        encounter form)
     How do mental health providers and
      primary care providers share
      information about mental health
      services?
―We can’t bill for mental health
services, so why code?‖

        You should still document in order
         to:
         ● Justify your position
         ● Assess mental health problems of
           school population
         ● Track treatment
         ● Track compliance
         ● Assist in measuring outcomes
         ● Demonstrate a need for mental health
           reimbursement
Documentation
  Where to document codes?

  •   Encounter Form
  •   Database

  BOTH (if separate):
   mental health chart AND
   medical record
Mental Health Diagnostic Codes
Anxiety Disorders
  300.01 Panic Disorder Without Agoraphobia

  300.21 Panic Disorder With Agoraphobia

  300.22 Agoraphobia Without History of Panic Disorder

  300.29 Specific Phobia
     Specify type: Animal Type/Natural Environment Type/Blood-Injection-Injury
     Type/Situational Type/Other Type

  300.23 Social Phobia
     Specify if Generalized

  300.3Obsessive-Compulsive Disorder
     Specify if With Poor insight

  309.81 Posttraumatic Stress Disorder
     Specify if Acute/Chronic
     Specify if With Delayed Onset

  308.3 Acute Stress Disorder

  300.02Generalized Anxiety Disorder

  300.00Anxiety Disorder NOS
Depressive Disorders
      296.xx Major Depressive Disorder
       ● .2x Single Episode
       ● .3x Recurrent


      300.4 Dysthymic Disorder

       Specify if Early Onset/Late Onset
       Specify With Atypical Features

      311 Depressive Disorder NOS
Disruptive Behavior Disorders
      314.xx Attention-Deficit/Hyperactivity Disorder
        ● .01 Combined Type
        ● .00 Predominantly Inattentive Type
        ● .01 Predominantly Hyperactive-Impulsive Type

      314.9 Attention-Deficit/Hyperactivity Disorder NOS

      312.xx Conduct Disorder
        ● .81 Childhood-Onset Type
        ● .82 Adolescent-Onset Type
        ● .89 Unspecified Onset

      313.81 Oppositional Defiant Disorder

      312.9 Disruptive Behavior Disorder NOS
Substance Abuse/Dependence
    303.90 Alcohol Dependence/305.00 Alcohol Abuse
    304.00Amphetamine Dependence/305.70 Amphetamine Abuse
    304.30 Cannabis Dependence/305.20 Cannabis Abuse
    304.20 Cocaine Dependence/305.60 Cocaine Abuse
    304.50 Hallucinogen Dependence/305.30 Hallucinogen Abuse
    304.60 Inhalant Dependence/305.90 Inhalant Abuse
    305.1 Nicotine Dependence
    304.00 Opioid Dependence/305.50 Opioid Abuse
    304.60 Phencyclidine Dependence/305.90 Phencyclidine Abuse
    304.10 Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative,
     Hypnotic, or Anxiolytic Abuse
    304.80 Polysubstance Dependence
    304.90 Other (or Unknown) Substance Dependence
    305.90 Other (or Unknown) Substance Abuse

     The following specifiers apply to Substance Dependence as noted:
     With Psychological Dependence/Without Psychological Dependence
     Early Full Remission/Early Partial Remission/Sustained Full
     Remission/Sustained Partial Remission In a Contained Environment On Agonist
     Therapy
Mental Health Procedural Codes
Evaluation & Management (E&M) Codes

     99201 – 99215 New and Established Patient Office
     Visits

     99241 - 99245 Consultations

     99361 - 99362 Case Management Services, Team
     Conferences

     99371 - 99373 Case Management Services,
     Telephonic
Mental Health Procedure
Codes
   90801 - 90802 Psychiatric Diagnostic or Evaluative
     Interview Procedures

   90804 - 90829 Psychotherapy
          90804 - 90815 Office or Other Outpatient Facility
          90810 - 90815 Interactive Psychotherapy
          90816 - 90829 Inpatient Hospital, Partial Hospital
          or Residential Care Facility

   90845 - 90857 Other Psychotherapy

   90862 - 90889 Other Psychiatric Services or Procedures
Psychiatric Therapeutic Procedures

        CPT Codes 90804 – 90889

        Psychotherapy is the treatment for mental
         illness and behavioral disturbances in
         which the clinician establishes a
         professional contract with the patient and,
         through definitive therapeutic
         communication, attempts to alleviate the
         emotional disturbances, reverse or change
         maladaptive patterns of behavior, and
         encourage personality growth and
         development.
E&M Codes and MH Codes
   The Evaluation and Management services
   should not be reported separately, when
   reporting codes:

   90805, 90807, 90809, 90811, 90813, 90815,
   90817, 90819, 90822, 90824, 90827, 90829.
Reimbursement – who can bill?
   What are the rules governing who can bill for
   mental health diagnosis/treatment in your
   state?
    ● Most states accept physicians (MD),
      clinical psychologists (CP), licensed
      clinical social workers (LCSW)
    ● However, each State has its own rules
      and many will pay for other professionals
Coverage Issues
                                Do you, as a provider, know if all
     A provider should          services provided are covered?
      know what services
                                Are you documenting properly, and
      are covered.               what about this ―medically
                                 necessary‖ bit?
     Services must be
      documented and
      medically necessary
      in order for payment
      to be made.
How Much are you Paid?

       Reimbursement
        ● Reductions in reimbursement rates by
         provider type
          ● Physician               - not discounted
          ● Clinical Psychologist   - discounted
          ● LCSW                    - further discounted
          ● Other                   - discounted if
                                            covered
Reimbursement 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:
Fraud 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‖
      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
Action Steps for
Mental Health Coding Improvements


              T
Questions to Answer
     What criteria must programs (SBHC) meet in order to
      provide behavioral health services?

     What providers are eligible to provide behavioral health
      services?

     What are your state’s credentialing and licensing
      requirements for providers of behavioral health
      services?

     What credentialing and licensing requirements are
      necessary for billing in your state?

     What are the guidelines for billing services as ―incident
Review Program Services

      Define the Behavioral/Mental Health
       Services your students are receiving

      Determine if there are additional
       Behavioral/Mental Health Services you
       want to provide
Review and Modify Encounter Form
      Does encounter form include both diagnostic
       and procedural codes that would be used for
       behavioral health when delivered by primary
       care providers? Mental health providers?

      Do procedural codes represent all services
       provided (including those not billed for)?

      Do diagnostic codes represent all diagnostic
       categories (including those not billed for)?
Review and Modify Documentation Procedures

       Are diagnostic and procedure codes
        documented for in each progress note?

        Are codes for each encounter documented
        in both the SBHC medical record and mental
        health chart (if separate)?

       Are codes entered into database regardless
        of reimbursement?
Understand State Program and Provider
Coverage Issues
      Research State Program Information
          ●   www.cms.gov (Medicare Regulations)
          ●   Search by state by Department of Health or
              Department of Mental Health to find state specific
              information


      Contact State Medicaid Assistance Program
       and determine specific Behavioral Health
       Service requirements

      Invite Medicaid Representatives to your
       facility or visit them to present Behavioral
       Health Program and clearly understand the
       requirements
Determine Reimbursement Estimates

      Obtain reimbursement rates by provider type
       for state and other programs

      Understand billing rules by payer, e.g. billing
       E&M visit same day as Behavioral Health
       visit, number of visits limits, auth/pre-
       authorizations, etc.

      Assure you have a complete understanding
       of program parameters re: Individual
       Therapy, Case Management, Special
       Behavioral Health Services, etc.
Common Pitfalls in
    Coding




                     106
     ICD-9 CM (Clinical Modification)
        Coding Guidelines
     Order to list ICD-9 codes
Coding Order is Important
1.    Acute Reason patient is being seen
      needs to be listed first.
2.    Co-morbid diagnosis affecting treatment
      of principal diagnosis are listed next.
3.    List all other documented conditions
      coexisting at the time of the visit that
      require or affect patient care, treatment or
      management. Chronic diseases may be
      listed as often as they are treated
                                                     107
ICD-9-CM Coding Guidelines
    DO NOT CODE:
     ● Conditions previously treated that no
       longer exist.
     ● Conditions that do not affect treatment
       or management at the current visit.
     ● Rule-out, suspected, questionable or
       probable diagnoses.


                                                 108
ICD-9-CM Coding Guidelines
Review of Systems Documentation
    Cannot say ―all other negative‖
    Must list pertinent and negative
     findings
    Must have a way to determine which
     systems were reviewed
    A check list is acceptable




                                          109
About 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




                                                110
Sports Physicals
    They are not meant to be
     comprehensive physicals – their focus
     is different
    Check www.aafp.org for an appropriate
     form
    You can bill for a complete PE and a
     sports PE within the same year


                                             111
Acute Problems within a
Comprehensive Physical
      When doing a preventive health visit
       (V20.2) and there is a separate health
       acute problem – you can list both the
       preventive health visit code (first) and the
       acute visit code (second) – BUT THERE
       MUST BE ICD-9 CODES THAT JUSTIFY
       BOTH
      (the billing department must add a
       modifier)
                                                      112
   Be sure to know the
   Reason for the Visit


             Reason for
               Visit


Preventive     Acute      Counseling
   Visit        Visit        Visit


                                       113
Late Effects of Burns
   Late effects means the burn has healed.
     There should not be dressing changes.




                                             114
Counseling Visits
Counseling visits are when
client comes in to discuss a
problem only. No hands are
laid on the patient.




                               115
            Example
Dietary Surveillance & Counseling
   There must be a dietary problem in
   order to justify this code.




                                        116
Be Specific with the
  codes you use




                       117
784.1 Throat Pain
      EXCLUDES:
       ● Dysphagia 787.2
       ● Neck pain 723.1
       ● Sore throat 462
       ● Chronic 472.1




                           118
       AGAIN - About
Over-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



                                             119
Coding Compliance
      Audit




                    120
Poor example incorrect coding for
        documentation
See Handouts of Completed Note
       Sample 10a (handout 9)
               &
   Encounter Form 10a (handout 10)


                                     121
122
123
Analysis of incorrect coding
    for documentation



                               124
 Coding Audit Cheat Sheet
     Top half of form
                                      PATIENT IDENTIFIER____10a
                  CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
  Preventive Health – New patient              ______
  Preventive Health – Established patient ______
  Counseling Services– No Physical Complaint
         Is time recorded in chart?            YES _____ NO _____
         Is a counseling code used?            YES _____ NO _____
  Evaluation / Management Visit: where counseling determines time
         Is the total time of the visit recorded         YES _____ NO _____
         Is the time spent in counseling recorded        YES _____ NO _____
         Is a counseling code used?                      YES _____ NO _____
  Evaluation / Management Visit – NEW PATIENT
  Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES: 99203        ICDE-9 CODES:    625.3      DO THE CPT/ICD-9 CODES
                                                    CORRELATE?
                                                               YES __X___NO
  ______                                                                      125
    Coding Audit Cheat Sheet
      Bottom Half of Form
HISTORY AND EXAMINATION
   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

   EXAM                  0         1       4                5                8



CHART AUDIT LEVELS FOR E/M VISITS

   HPI, ROS, PFSH    3                     NEW PATIENT LEVEL                       2
                                            Lowest level supports level

   EXAMINATION       2                     ESTABLISHED PT LEVEL ____
                                            2 of 3 or middle level supports level


   MEDICAL DECISION MAKING   3                                                         126
Medical Decision Making
Section I: Diagnosis or Management of Problems

   99201    99202                99203              99204                 99205


   99211    99212                99213              99214                 99215
           One self-       Two or more self-   One or more chronic   One or more
           limited or      limited or minor    illnesses with        chronic illness with
           minor problem   problems            complications         severe
                                               Two or more stable    complications
                           -One stable         chronic conditions    Acute or chronic
                           chronic             Undiagnosed new       illness or injury that
                           condition           problem w/uncertain   is life or limb
                                               prognoses             threatening
                           -Acute              Acute illness with    Abrupt change in
                           uncomplicated       systemic symptoms     neurologic status
                           illness             Acute complicated
                                               injury                                  127
Medical Decision Making
Section II: Diagnostic Procedures
   99201     99202                99203               99204                  99205
   99211     99212                99213               99214                  99215
             Lab                  Physiologic tests   Physiologic tests      Cardiovascular
             X-ray                not under stress    under stress-          imaging with contrast
             EKG                  Pulmonary           cardiac stress tests   Invasive diagnostic
             UA                   Function            Diagnostic             tests
                                  Barium Enema        endoscopies with       Cardiac
             Ultrasound, etc.                         no risk factors
                                  Arterial puncture                          Electrophysiological
             Venipuncture                             Deep needle or         tests Diagnostic
             KOH                  Skin biopsies
                                                      incisional biopsy      endoscopies with
                                                      Obtained fluid from    identified risk factors
                                                      body                   Discography
                                                      Cardiovascular
                                                      imaging with
                                                      contrast




       Other levels of Diagnostic procedures do not usually apply to SBHC, but you only128
       need to have 2 of the 3 areas of medical decision making to agree.
Medical Decision Making
Section III: Treatment or Management Options

     99201     99202          99203               99204                       99205

     99211     99212          99213               99214                       99215

             Rest        OTCs            Minor surgery with risk     Elective Surgery with
             Gargles                     factors                     identified risk factors
                         Minor surgery
             Elastic                     Elective major surgery—     Emergency major
                         PT              no risk factors             surgery
             bandages
                         OT              Prescription drug           Parenteral controlled
             Dressings
                         IVs without     management                  substances
                         additives       IV fluids with additives    Drug treatment
                                         Closed facture or           requiring intensive
                                         dislocation treatment w/o   monitoring
                                         manipulation                Decision not to
                                         Therapeutic nuclear         resuscitate or de-
                                         medicine                    escalate care because
                                                                     of poor prognosis


                                                                                         129
 Unfortunately – Because of this
documentation/coding error - you
  will not get paid for this visit.
This is why it is very important to
            verify that
        charting supports
  all levels of coding decision
             making.
                                      130
Questions & Answers




                      131

				
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