Medical Coding 101

Coding 100Richard Lander MD FAAP

Why is coding important to me?

Coding tells the insurers & auditors what the patient’s problems were and what you did for them so that you can get paid.

Coding is how you will make your living.

What is a CPT and where do they come from?

CPT codes stands for Current Procedural Terminology. It is owned by the AMA. It is revised yearly and it is the standard for all

medical billing.

What is a RBRVU?

RBRVU stands for Resource Based Relative Value Units.

Developed at Harvard by Dr. Hsai to make Medicare payments more equitable, it is now the standard of

payment for many private insurers.

RBRVU

What is an ICD?

ICD tells what illness was discovered in your examinations

ICDs have “severity” scoring systems in existence that look to see that physicians are paid appropriately for the work they deliver

Well visits

With well visits you only need to know if the patient is “new” or “established. New patients –

one not seen by you or the practice in 3 years

Age CPT Code New CPT Code Established

Under 1 year 99381 99391

1 – 4 years 99382 99392

5 – 11 years 99383 99393

12 – 17 years 99384 99394

18 – 39 years 99385 99395

Well visits

Evaluation and Management Codes

E&M codes are for sick visits. They are based on the severity of the illness and work done.

Note: If more than 50% of visit is counseling, then time is an

element

New patient codes require all 3 elements

New Patients

Patients only require 2 out of 3 elements

Established

Doesn’t require the

presence of a physician

99211

Expanded problem focused history

Expanded problem focused exam

Straightforward medical decision making

99212

Detailed history

Detailed examination

Medical Decision making of low complexity

99213

Comprehensive history

Comprehensive examination

Medical decision making of moderate complexity

99214

Comprehensive history

Comprehensive examination

Medical decision making of high complexity

99215

Why is this important?

Most doctors (pediatricians, actually) under code

What does this cost?

0

10

20

30

40

50

60

70

80

90

Level I Level III Level IV

If you increase from 5% 99214 to 20% , you can increase your net income by $20,000 without doing any more work

You don’t want to over code because Medicaid and private health insurers can and will audit you. If the documentation

doesn’t equal the code billed, they will penalize you

Evaluation requested by an appropriate professional with a report back to that person

99243 - Consult

3.17 x 36.79

$116.62

99213 – E/M

1.39 x 36.79

$51.14

Pediatricians do many procedures

If you don’t bill for the procedures you do, you cheat yourself out of the many dollars

Subluxation of elbow

246404.85x 36.79

$178.43

99213 1.39 x 36.79

$51.14

What does this tell you?

It is critical to know the codes for all the procedures you do, since obviously procedures pay better than E/M codes

Where can you learn more?

Decide if the practice you are looking at has someone who knows coding

The Academy offers coding courses – at the NCE and as stand alone courses

Other Steps

Be sure you have a current CPT and ICD coding books in your office

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