The Coding Primer

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					   The Coding Primer

“How to Code” basics for primary
        care providers.
       Updated for 2009
Coding: “Can’t Live With It. Can’t
        Live Without It.”
• Coding is important because it builds the
  electronic health record.

• It is the language we use to collect our

• It has become and will become even more
  the means by which we will be alotted
  cash and manpower.
     How are we doing now?
• 573 encounters audited by our coders in
  August 2007.
• 84.05% Diagnosis correct.
• 74.57 % Eval/management codes correct.
• 67.18 % CPT codes correct. Document
  what you performed. Method / Location /
  Quantity / Size / Layers / Time frames.
• 51 % of encounters had errors found!
                  In general…
• Code only what you know. If the diagnosis is “likely” or
  rule-out code for the symptoms the patient is having.
  E.g. CHF rule out can be coded as lower leg swelling.

• Don’t code for resolved conditions. Instead use the
  v67 series for follow up exams.

• List complicating factors. Comorbidities, other chronic
  conditions the patient may have, adverse effects of
  medications that may be indicated. Helps to determine
  the complexity of the decision making process you are
              In general…
• Try to be clear about taking intermediate
  steps to address a patient’s condition.
  This can boost the complexity of the
  condition to the coder. Trying first physical
  therapy, nsaids prior to surgical
  consideration for example.
• Use the “50%” button as the exception,
  not the rule.
             In general…
• Be specific about reviews of labs or
  xrays. Labs reviewed with patient showed
  elevated wbc indicating sepsis or
  inflammation. If a patient is following up
  blood pressure check tell what was wrong
  with the blood pressure to begin with.
• Be sure to add the nurse, MA or corpstaff
  as an additional provider to help show
  clinic workload.
              In general…
• Medical necessity should drive ordering of
  labs or other diagnostic studies. Write a
  story that tells why these labs need to be
  done. The complexity of the office visit is
  based on the story not on the fact that so
  many labs were ordered.
• When applicable, code “obesity” as it
  can help to increase the medical decision
  making score.
             In general…
• Collect credit for diagnostic decisions.
  If the provider went through the medical
  decision making process to determine a
  patient needed a certain test, even though
  the patient refused the test, the provider
  should receive credit for that process,
  provided the process is documented. E.g.
  colonoscopy screening / tobacco
  cessation counseling / obesity nutrition
             In general…
• For residents…Give name of staff you
  discussed the case with.
• Vital signs must be stated to have been
• EKG must be reviewed in your note to
  obtain credit for having done it (CPT
• LOOK! At your clinic favorites for CPT
  codes and for Diagnoses!
    Code for the -25 modifier.
• When a procedure is done separate from
  the office visit diagnosis. When providing
  a specific treatment plan during a prev
  med visit. E.g. during a PAP smear patient
  brings up depression and you counsel and
  provide medical therapy. During an EST
  patient elects to start tobacco cessation
  and you perform counseling.
      How to: Code for Preventive Med Visits
• V20.2 visit for: Well baby, Well
• V72.31 Normal Pelvic Exam
  with Cervical PAP (Well
• V76.2 Screening Pap
• V70.0 Normal Routine History
  and Physical (Well Adult)
• V70.3 School/Camp Physical

• Disposition: Age-Appropriate
  Prev Med Code! E.g. 99395
  RVU = 1.36 (99213RVU =
        How to: Code for Routine OB Care
• V22.0 Supervision of Normal
  First Pregnancy
• V22.1 Supervision of
• V22.2 Pregnancy incidental to

• CPT ! : NOB = 0500f,
  Antepartum = 0502f, Post-
  Partum Exam = 0503f
• Disposition : 99499

  99499 with 0500.0502,0503 =
  0.83 rvu !
            How to: Code for Well Woman Visit
•   V72.31 Routine Physical Exam with a
    GYN component. When cervical PAP
    Smear is performed must add
    diagnosis V76.2 Screening PAP.
•   If s/p hysterectomy V72.31 still applies
    with V76.47 for vaginal PAP.

•   CPT/HCPCS!: “Q0091” Obtain PAP /
    Transport to Lab
•   87210 wet prep/koh (done and
    interpreted in clinic) 82272 Hemoccult
    from DRE (done in clinic).

•   Q0091 RVU = 0.37
•   Disposition: Use age-appropriate
    Prev Med Code!
How to: Code Tobacco Cessation
               •   305.1 Nicotine Dependence

               • New!      CPT: in E&M section
                   add “Additional E&M” code
                   using -25 modifier.
               •   99406: 3-10 minutes of cessation
               •   99407: > 10 minutes of cessation
               •   96153: provider group visit
               •   HCPCS S9453: non-provider
                   cessation counseling

               •   99406 RVU = 0.24
               •   99407 RVU = 0.50
How to: Code Obesity

            278.00 Obesity
            (bmi 30-39)
            278.01 Morbid
            Obesity (bmi>39)
            278.02 Overweight
            (bmi 25-29)

          • V77.8 visit for:
            screening exam
             How to: Code for Skin Biopsies

•   Punch / Shave Biopsy of:
•   Macules and Papules 709.8
•   Subcutaneous Nodule 782.2
•   Acrochordon 701.9

•   CPT Biopsy Skin:11100
•   Each additional biopsy: 11101

•   CPT Skin tag removal: 11200
    (up to 15 lesions)
•   Each additional 10 biopsies:

•   CPT Destruction of benign
    lesion by cryotherapy: 17110: up
    to 14 lesions 17111: 15 or more
   How To: Code for Exercise Stress Testing

• Exercise Stress Test:
  786.50 Chest pain or
  v81codes visit for:
  screening exam
  cardiovascular disorders
  (no hx recent chest pain)
• CPT Cardiovascular
  Stress Test: 93015
• CPT Stress Test with
  Challenge: 93015
How To: Code for Colposcopy

              • Colposcopy Diagnosis:
                795. series Abnl PAP of
              • CPT Colposcopy without
                biopsy 57452
              • CPT Colposcopy with
                biopsy of cervix and ECC
              • CPT Colposcopy with
                ECC only 57456
              • CPT Colposcopy with
                biopsy only 57455
          How To: Code for Vasectomy

• Pre Vasectomy
  Counseling and
  Examination: v25.09

• Vasectomy Procedure:
  v25.2 Surgery of Male
  Genitalia Sterilization
• CPT 55250

• Post-Vasectomy
  Follow-up: v67.00
How To: Code Chronic Kidney Disease

                  • 585.9 Chronic Kidney
                    Disease (NKF
                  • 403.9 Hypertensive
                    Chronic Kidney
     How To: Code Adverse Drug Reaction

• E947.9 Adverse
  Effect of Drug

• Enter Medication as
  “ADR” / list effect drug
  had on patient.
How To: Code for Diabetes
             • Diabetes 250.00
             • Pre-Diabetes (Impaired
               Glucose Tolerance)
             • Gestational Diabetes
             • Visit for: Screening Exam
               Diabetes v77.1

             • CPT: for Foot Exam
             • 2028F: for normal exam
               G0247: if neuropathy is
  How To: Code for Alcohol Use Counseling

• 305.00 Alcohol
  abuse, unspecified

• 303.90 Alcoholism,
   How To: Code for Mammogram Review /
• Mammogram
  Screening: v76.12

• CPT: Review
  Mammogram Results
How To: Code for Osteoporosis Screening

                    • Osteoporosis 733.00

                    • Visit for : screening
                      exam osteoporosis

                    • Anticipatory
                      Osteoporosis v65.49
   How To: Code for Colon Cancer Screening

• Visit for: Screening
  neoplasm malignant
  colon. V76.51

• Heme Occult testing
  CPT: 82272 if
  interpretation is
  performed in the clinic

• Flex Sig CPT: 45330
       How to: Code for Screening Exams

• V76.51 screening colon
• V77.1 screening,
• V76.9 screening cancer,
• V77.91 screening lipid
• V81.0 screening cardiac
• V82.9 screening,

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