Coding 101 The Partnership TOT, September 22, 2008 Taken from “Beginning Coding”, “Intermediate Coding”, and “I Hate Coding” by Dianne Demers

Coding 101Coding 101

The Partnership TOT, September 22, 2008The Partnership TOT, September 22, 2008

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

2

Welcome and ExpectationsWelcome and Expectations

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ObjectivesObjectives

The Participant will be able toThe Participant will be able to ● DefineDefine CPT, ICD 9, and DSM 4 CodingCPT, ICD 9, and DSM 4 Coding● ExplainExplain the reasons why appropriate coding the reasons why appropriate coding

and documentation is so important in SBHC and documentation is so important in SBHC settings. settings.

● DemonstrateDemonstrate correct use of CPT and ICD 9 correct use of CPT and ICD 9 codescodes

● Explain Explain the rational for conducting routine the rational for conducting routine medical record review and coding medical record review and coding compliance audits in SBHC settingscompliance audits in SBHC settings

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Coding Background and Coding Background and TerminologyTerminology

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Coding DefinitionCoding Definition

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

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Types of Coding Types of Coding

Current Procedural Terminology (CPT)Current Procedural Terminology (CPT) International Classification of Diseases International Classification of Diseases

(ICD-9 Clinical Modification - CM)(ICD-9 Clinical Modification - CM) Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental

Disorders (DSM IV-TR)Disorders (DSM IV-TR)

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Coding Is Not The Coding Is Not The Same As BillingSame As Billing

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Coding is Medicare DriveCoding is Medicare Drive

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

9

SBHC CodingSBHC Coding

There is no difference between coding There is no difference between coding in a SBHC and any other setting – the in a SBHC and any other setting – the coding assumptions are the same.coding assumptions are the same.

You provide the same level of care You provide the same level of care regardless of the location.regardless of the location.

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Why Code Correctly?Why Code Correctly?

●Reimbursement depends on it.Reimbursement depends on it.●Codes describe the services you Codes describe the services you

provideprovide●Codes justify these servicesCodes justify these services● Services not documented “never Services not documented “never

happened”happened”

PS: Never code for the purpose of PS: Never code for the purpose of getting more money getting more money

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The Coding Process has 2 PartsThe Coding Process has 2 Parts

1.1. “What you did” = CPT “What you did” = CPT

2.2. “Why you did it” = ICD-9 or DSM-4 TR “Why you did it” = ICD-9 or DSM-4 TR

YOU MUST ALWAYS USE BOTHYOU MUST ALWAYS USE BOTH

a what and a whya what and a why

(NO EXCEPTIONS)(NO EXCEPTIONS)

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When a provider is under-When a provider is under-coding they tell the wrong storycoding they tell the wrong story

This wrong story is:This wrong story is: SBHC Providers are seeing very few SBHC Providers are seeing very few

patients with multiple problems.patients with multiple problems. SBHC Providers should see more SBHC Providers should see more

patients since they are not seeing patients since they are not seeing complicated patients.complicated patients.

The SBHC should decrease the The SBHC should decrease the number of physicians and add more number of physicians and add more mid-level providers.mid-level providers.

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There Are Two Coding There Are Two Coding Guidelines - 1995 & 1997Guidelines - 1995 & 1997 Both 1995 and 1997 guidelines are Both 1995 and 1997 guidelines are

approved for use by CMSapproved for use by CMS Agencies may specify use of 1995 or Agencies may specify use of 1995 or

1997 guidelines1997 guidelines 1997 guidelines are more specific than 1997 guidelines are more specific than

1995 in the examination portion (they 1995 in the examination portion (they are more computer friendly)are more computer friendly)

New guidelines have been proposed, New guidelines have been proposed, but have not yet been acceptedbut have not yet been accepted

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Coding Guidelines Coding Guidelines 1995 vs. 19971995 vs. 1997

This lecture is based on the 1995 This lecture is based on the 1995 guidelines because they are 15 pages guidelines because they are 15 pages long vs. 57 pages of the 1997 version.long vs. 57 pages of the 1997 version.

www.cms.hhs.gov/MLNProducts/www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdfDownloads/1995dg.pdf

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FraudFraud

IntentionalIntentional deception or deception or misrepresentationmisrepresentation● Deliberately billing for services not Deliberately billing for services not

performedperformed● Unbundling of servicesUnbundling of services● Intentionally submitting duplicate claimsIntentionally submitting duplicate claims

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AbuseAbuse

Improper billing practicesImproper billing practices● Billing for non-covered servicesBilling for non-covered services● Misusing codes on a claim formMisusing codes on a claim form

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ErrorsErrors

Accept it, you will Accept it, you will make them.make them.

Your best defense Your best defense is having a plan for is having a plan for your coding and your coding and being able to being able to explain it.explain it.

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Coding Does Not Coding Does Not Equal Good Equal Good

MedicineMedicine

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But - Coding is Good But - Coding is Good DocumentationDocumentation

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CPT Codes document:CPT Codes document:

Level of ServiceLevel of Service

Procedures ProvidedProcedures Provided

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Examples of CPT codesExamples of CPT codes

Evaluation Evaluation & &

Management Management 9921199211

9921299212 9921399213 9921499214 9921599215

Preventive Health99391993929939399394993959939799397

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ICD-9 and DSM4 Codes ICD-9 and DSM4 Codes document:document:

The The reason reason behind the visitbehind the visit

(They must support the CPT codes)(They must support the CPT codes)

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General Coding PrinciplesGeneral Coding Principles

Coding gets you paid for your servicesCoding gets you paid for your servicesCoding can be used to justify the need Coding can be used to justify the need

for services to your fundersfor services to your funders

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Coding with ICD-9Coding with ICD-9 ICD-9 codes have 3, 4 or 5 digitsICD-9 codes have 3, 4 or 5 digits● The greater the number of digits, the The greater the number of digits, the

higher the specificityhigher the specificity●Use a 5-digit code when it existsUse a 5-digit code when it exists●Use a 4-digit code only if there is no 5-Use a 4-digit code only if there is no 5-

digit code with the same categorydigit code with the same category●Use a 3-digit code only if there is no 4-Use a 3-digit code only if there is no 4-

digit code within the same categorydigit code within the same category

PS: Omitting the required 4PS: Omitting the required 4thth or 5 or 5thth digit will digit will result in the denial of a claim. Do not add any result in the denial of a claim. Do not add any additional digits, even zeroadditional digits, even zero

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ICD-9-CM CodesICD-9-CM Codes

Range from 001.0 to V82.9Range from 001.0 to V82.9They identify:They identify:● DiagnosesDiagnoses● SymptomsSymptoms● ConditionsConditions● ProblemsProblems● ComplaintsComplaints● Other reason for the procedure, service, or Other reason for the procedure, service, or

supply providedsupply provided

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ICD-9-CM CodesICD-9-CM Codes Three volumesThree volumes● Volume 1 Tabular List of DiseasesVolume 1 Tabular List of Diseases

●Notes all exclusive terms and 5Notes all exclusive terms and 5 thth-digit -digit instructionsinstructions

● Volume 2 Alphabetic Index of DiseasesVolume 2 Alphabetic Index of Diseases●Does not contain detail – Do Not code Does not contain detail – Do Not code

from this volumefrom this volume● Volume 3 ProceduresVolume 3 Procedures

●Used almost exclusively for hospital Used almost exclusively for hospital servicesservices

PS: (All 3 Volumes are generally found in one binding)PS: (All 3 Volumes are generally found in one binding)

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““V” CodesV” Codes For circumstances other than disease or injuryFor circumstances other than disease or injury Three categories:Three categories:● Problem Problem – Could affect overall health – Could affect overall health

status, but is not a current illness or injurystatus, but is not a current illness or injury● Ex.: V14.2 Personal history of allergy to Ex.: V14.2 Personal history of allergy to

sulfonaminessulfonamines● ServiceService – Circumstances other than illness – Circumstances other than illness

or injuryor injury● Ex.: V68.1 Issue of a repeat prescriptionEx.: V68.1 Issue of a repeat prescription

● Factual Factual – Certain facts that do not fall into – Certain facts that do not fall into the “problem” or “service” categoriesthe “problem” or “service” categories

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““V” CodesV” Codes

Can be used as a:Can be used as a:● Solo CodeSolo Code● Principal codePrincipal code● Secondary codeSecondary code

May represent check-ups, screenings, May represent check-ups, screenings, administrative requests, prescription administrative requests, prescription refillsrefills

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Rules for CodingRules for Coding Outpatient Visits Outpatient Visits

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Determine Type of Office Visit Determine Type of Office Visit Evaluation and ManagementEvaluation and Management

New Patients vs. Established PatientsNew Patients vs. Established Patients

Preventive Health VisitsPreventive Health Visits New Patients vs. Established PatientsNew Patients vs. Established Patients

Counseling VisitsCounseling Visits Medical Visit – talker onlyMedical Visit – talker only

Mental Health VisitsMental Health VisitsNew Patients vs. Established PatientsNew Patients vs. Established Patients

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Determine Medical NecessityDetermine Medical Necessity

Services are reasonable and Services are reasonable and necessary for the diagnosis and necessary for the diagnosis and treatment of illness or injury.treatment of illness or injury.

All payors define necessity differentlyAll payors define necessity differentlyClinical rationale must be documented Clinical rationale must be documented

through coding.through coding.You cannot write more, to get paid You cannot write more, to get paid

more.more.

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Determine Chief ComplaintDetermine Chief Complaint

The reason for the patient’s visitThe reason for the patient’s visit● S of a SOAP noteS of a SOAP note

Codes used must relate to chief Codes used must relate to chief complaint or they are invalidcomplaint or they are invalid

And, the chief complaint must be And, the chief complaint must be documented in the chartdocumented in the chart

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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services

Used for acute care visitsUsed for acute care visitsFive levels of serviceFive levels of serviceSeven components within the levelsSeven components within the levels● Key components – history, exam and Key components – history, exam and

medical decision makingmedical decision making● Contributory components – counseling, Contributory components – counseling,

coordination of care, nature of presenting coordination of care, nature of presenting problem, and timeproblem, and time

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Beginning information about coding Beginning information about coding deals with the three key components:deals with the three key components:● HistoryHistory● ExaminationExamination● Medical Decision MakingMedical Decision Making

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There are 5 Levels of serviceThere are 5 Levels of service1.1. MinimalMinimal

2.2. Self-Limited or MinorSelf-Limited or Minor

3.3. Low SeverityLow Severity

4.4. Moderate SeverityModerate Severity

5.5. High SeverityHigh Severity

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CPT Codes Used for E/M VisitsCPT Codes Used for E/M Visits

New PatientsNew Patients

Level 1 99201Level 1 99201Level 2 99202Level 2 99202Level 3 99203Level 3 99203Level 4 99204Level 4 99204Level 5 99205Level 5 99205

Established PatientsEstablished Patients

9921199211 9921299212 9921399213 9921499214 9921599215

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Coding StepsCoding Steps

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First StepFirst Step - - Determine if your patient is: Determine if your patient is:

A New Patient A New Patient or or

An Established PatientAn Established Patient

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Definition of a new patient:Definition of a new patient:

It is the patient’s first visit to the providerIt is the patient’s first visit to the providerThe patient has not received any The patient has not received any

professional services from the provider professional services from the provider or another provider of the same specialty or another provider of the same specialty who belongs to the same group practice, who belongs to the same group practice, within the past three years.within the past three years.

PS: Any time a patient is seen in an PS: Any time a patient is seen in an Emergency Room they are considered a Emergency Room they are considered a new patientnew patient

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If your patient does not If your patient does not meet the definition of a meet the definition of a

New PatientNew Patient, , then they are an then they are an

Established PatientEstablished Patient

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Coding StepsCoding StepsSecond Step - Second Step - determine the level of determine the level of

service for the visit, service for the visit,

To do this you need to determine the level of To do this you need to determine the level of service for each key component separatelyservice for each key component separately

There are 3 key componentsThere are 3 key components

They are:They are:1. History (HPI, ROS, PFSH)1. History (HPI, ROS, PFSH)2. Examination2. Examination3. Medical Decision Making3. Medical Decision Making

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New PatientsNew PatientsWithin the 3 key components, there are Within the 3 key components, there are

5 levels of service5 levels of serviceRemember to Consider the Key Remember to Consider the Key

Components separately:Components separately:● HPI, ROS, PFSHHPI, ROS, PFSH● ExaminationExamination● Medical Decision MakingMedical Decision Making

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Example - New PatientExample - New PatientThe Level of Service for a new patient visit is The Level of Service for a new patient visit is determined by the lowest level of service (1 determined by the lowest level of service (1

through 5) of the three key componentsthrough 5) of the three key components

HPI, ROS, PFSH 4

Examination 4

Medical Decision Making

3This is the lowest level

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Established PatientsEstablished PatientsAgain Consider the Key Components Again Consider the Key Components

Separately:Separately:● HPI, ROS, PFSHHPI, ROS, PFSH● ExaminationExamination● Medical Decision MakingMedical Decision Making

The level of service (1 – 5) is The level of service (1 – 5) is determined by the level that appears in determined by the level that appears in 2 of the three components, or by the 2 of the three components, or by the middle level middle level

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Example – Established PatientExample – Established Patient

HPI, ROS, PFSH

3This is the middle level

EXAM 2

Medical Decision Making 4

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Why is this?Why is this?

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Answer . . . Answer . . . There has to be a There has to be a

system, and this is what system, and this is what AMA came up with.AMA came up with.

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Coding Jeopardy/ Coding Jeopardy/ Match GameMatch Game

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How to Steps of CodingHow to Steps of Coding

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How to Steps of Coding: How to Steps of Coding: Determine Level of Medical Decision MakingDetermine Level of Medical Decision Making

Determine Level of History ComponentDetermine Level of History ComponentDetermine Level of Physical ExaminationDetermine Level of Physical Examination

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

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Determine Level of Medical Determine Level of Medical Decision MakingDecision Making

Medical Decision Making consists of Medical Decision Making consists of three sections:three sections:● Diagnosis or Management ProblemsDiagnosis or Management Problems● Diagnostic ProceduresDiagnostic Procedures● Treatment of Management OptionsTreatment of Management Options

Level is determined by the level found Level is determined by the level found in two of the three categories – or the in two of the three categories – or the middle number if all three are differentmiddle number if all three are different

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

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215One self-limited or minor problem

Two or more self-limited or minor problemsOne stable chronic conditionAcute uncomplicated illness

One or more chronic illnesses with complications

Two or more stable chronic conditionsUndiagnosed new problem w/uncertain prognoses

Acute illness with systemic symptomsAcute complicated injury

One or more chronic illness with severe complicationsAcute or chronic illness or injury that is life or limb threateningAbrupt change in neurologic status

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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section II: Diagnostic ProceduresSection II: Diagnostic Procedures

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

LabX-rayEKGUAUltrasound, etc.VenipunctureKOH

Physiologic tests not under stressPulmonary FunctionBarium EnemaArterial punctureSkin biopsies

Physiologic tests under stress-cardiac stress testsDiagnostic endoscopies with no risk factorsDeep needle or incisional biopsyObtained fluid from bodyCardiovascular imaging with contrast

Cardiovascular imaging with contrastInvasive diagnostic testsCardiac Electrophysiological tests Diagnostic endoscopies with identified risk factorsDiscography

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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section III: Section III: Treatment or Management OptionsTreatment or Management Options

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

RestGarglesElastic bandagesDressings

OTCsMinor surgeryPTOTIVs without additives

Minor surgery with risk factorsElective major surgery—no risk factors

Prescription drug managementIV fluids with additivesClosed facture or dislocation treatment w/o manipulationTherapeutic nuclear medicine

Elective Surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug treatment requiring intensive monitoringDecision not to resuscitate or de-escalate care because of poor prognosis

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How to Steps of Coding: How to Steps of Coding: Determine Level of History Component Determine Level of History Component

History component consists of three History component consists of three sections:sections:● History of Present Illness (HPI)History of Present Illness (HPI)● Review of Systems (ROS)Review of Systems (ROS)● Patient, Family, and Social History (PFSH)Patient, Family, and Social History (PFSH)

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Determine Level of History ComponentDetermine Level of History Component

Section I: History of Present IllnessSection I: History of Present Illness LocationLocation QualityQuality SeveritySeverity DurationDuration TimingTiming ContextContext Modifying factorsModifying factors Associated signs and symptomsAssociated signs and symptoms

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Determine Level of History ComponentDetermine Level of History Component

Section II: Review of SystemsSection II: Review of Systems Constitutional symptoms (fever, wt loss, etc.)Constitutional symptoms (fever, wt loss, etc.) EyesEyes Ears, nose, mouth, throatEars, nose, mouth, throat CardiovascularCardiovascular RespiratoryRespiratory GastrointestinalGastrointestinal GenitourinaryGenitourinary MusculoskeletalMusculoskeletal Integumentary (skin and/or breast)Integumentary (skin and/or breast) NeurologicNeurologic PsychiatricPsychiatric EndocrineEndocrine Hematologic/lymphaticHematologic/lymphatic Allergic/immunologicAllergic/immunologic

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Determine Level of History ComponentDetermine Level of History Component Section III: Patient, Family and Social HistorySection III: Patient, Family and Social History

Past medical historyPast medical history● Medication allergiesMedication allergies

Patient’s family historyPatient’s family history Patient’s social historyPatient’s social history● Age-appropriate review of past and Age-appropriate review of past and

current activitiescurrent activities● Tobacco usageTobacco usage

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History Component MatrixHistory Component Matrix(Number of components of each HPI, (Number of components of each HPI, ROS & PFSH required for each level)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

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How to of Coding Steps: How to of Coding Steps: Determine Level of Physical ExaminationDetermine Level of Physical Examination

ConstitutionalConstitutional EyesEyes Ears, Nose, Mouth, ThroatEars, Nose, Mouth, Throat CardiovascularCardiovascular RespiratoryRespiratory GastrointestinalGastrointestinal GenitourinaryGenitourinary MusculoskletalMusculoskletal SkinSkin NeurologicNeurologic PsychiatricPsychiatric Hematologic/Lympatic/ImmunologicHematologic/Lympatic/Immunologic

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Determine Level of Physical Examination:Determine Level of Physical Examination:# of body systems required for each level# 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

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Coding Matrix Example:Coding Matrix Example:

New Patient Established Patient

History 3 3

Exam 2 2


3 3

Level of Coding 2 3

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Coding Matrix Example:Coding Matrix Example:

New Patient Established Patient

History 4 4

Exam 2 2


4 4

Level of Coding 2 4

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Coding ExerciseCoding Exercise

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Coding Exercise for Evaluation/ Coding Exercise for Evaluation/ Management ServicesManagement Services

Suzy Q is a 16 y/o female with c/o Suzy Q is a 16 y/o female with c/o severe “female” cramps - worse than usual.severe “female” cramps - worse than usual.She states she took Midol and it onlyShe states she took Midol and it onlyhelped a little. She is a new patient. helped a little. She is a new patient. Document on the exam and encounter Document on the exam and encounter form to a level 3, using audit sheet form to a level 3, using audit sheet as reference. as reference.

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68

69

How to Verify this is correct How to Verify this is correct level of documentation to level of documentation to

support level 3support level 3

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Count the componentsCount the components

HRI 1 - MidolHRI 1 - Midol

ROS 1 - crampsROS 1 - cramps

PFSH - 0PFSH - 0

______________________

Level 3Level 3

Exam 1-constExam 1-const

2-Abd2-Abd

3-back3-back

4-genito4-genito

________________________

Level 3Level 3

Med DecisionMed Decision

- acute/uncomp- acute/uncomp

- OTCs- OTCs

______________________

Level 3Level 3

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Preventive ServicesPreventive Services

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These visits include a These visits include a comprehensive history and comprehensive history and examination, as well as appropriate examination, as well as appropriate counseling/anticipatory counseling/anticipatory guidance/risk factor reduction, guidance/risk factor reduction, interventions, and the ordering of interventions, and the ordering of age-appropriate age-appropriate laboratory/diagnostic procedures.laboratory/diagnostic procedures.

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““Comprehensive” in a preventive Comprehensive” in a preventive service examination is not service examination is not synonymous with a “comprehensive” synonymous with a “comprehensive” E/M examination.E/M examination.

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Preventive Service CodesPreventive Service Codes

Age New Established< 1 99381 993911-4 99382 993925-11 99383 9939312-17 99384 9939418-39 99385 9939540-64 99387 9939765+ 99387 99397

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Appropriate ICD-9 codes would be:Appropriate ICD-9 codes would be:

V20.2V20.2 for a for a Routine Infant or Child Health Routine Infant or Child Health CheckCheck

V70.3V70.3 for a for a Sports PhysicalSports Physical

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Additional services provided at the time Additional services provided at the time of the visit should be reported with their of the visit should be reported with their specific CPT codes listed separately:specific CPT codes listed separately:● Examples:Examples:

● Snellen TestSnellen Test● LaboratoryLaboratory● ImmunizationsImmunizations● Administration of ImmunizationsAdministration of Immunizations

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Mental Health ServicesMental Health Services

How do you document mental How do you document mental health services?health services?

Who documents mental health Who documents mental health services?services?

Where are mental health services Where are mental health services documented? documented? ● (mental health chart, medical record, (mental health chart, medical record,

both charts, log sheet, database, both charts, log sheet, database, encounter form)encounter form)

How do mental health providers and How do mental health providers and primary care providers share primary care providers share information about mental health information about mental health services?services?

““We can’t bill for mental health We can’t bill for mental health services, so why code?”services, so why code?”

You should still document in order You should still document in order to:to:● Justify your positionJustify your position● Assess mental health problems of Assess mental health problems of

school populationschool population● Track treatmentTrack treatment● Track complianceTrack compliance● Assist in measuring outcomesAssist in measuring outcomes● Demonstrate a need for mental health Demonstrate a need for mental health

reimbursementreimbursement

DocumentationDocumentation

Where to document codes?Where to document codes?

• Encounter FormEncounter Form• DatabaseDatabase

BOTH (if separate):BOTH (if separate): mental health chart ANDmental health chart AND medical recordmedical record

Mental Health Diagnostic CodesMental Health Diagnostic Codes

Anxiety DisordersAnxiety Disorders300.01 Panic Disorder Without Agoraphobia300.01 Panic Disorder Without Agoraphobia

300.21 Panic Disorder With Agoraphobia300.21 Panic Disorder With Agoraphobia

300.22 Agoraphobia Without History of Panic Disorder300.22 Agoraphobia Without History of Panic Disorder

300.29 Specific Phobia300.29 Specific PhobiaSpecify type: Animal Type/Natural Environment Type/Blood-Injection-Injury Specify type: Animal Type/Natural Environment Type/Blood-Injection-Injury Type/Situational Type/Other TypeType/Situational Type/Other Type

300.23 Social Phobia300.23 Social PhobiaSpecify if GeneralizedSpecify if Generalized

300.3Obsessive-Compulsive Disorder300.3Obsessive-Compulsive DisorderSpecify if With Poor insightSpecify if With Poor insight

309.81 Posttraumatic Stress Disorder309.81 Posttraumatic Stress DisorderSpecify if Acute/ChronicSpecify if Acute/ChronicSpecify if With Delayed OnsetSpecify if With Delayed Onset

308.3 Acute Stress Disorder308.3 Acute Stress Disorder

300.02Generalized Anxiety Disorder300.02Generalized Anxiety Disorder

300.00Anxiety Disorder NOS300.00Anxiety Disorder NOS

Depressive DisordersDepressive Disorders

296.xx Major Depressive Disorder296.xx Major Depressive Disorder● .2x Single Episode.2x Single Episode● .3x Recurrent.3x Recurrent

300.4 Dysthymic Disorder300.4 Dysthymic Disorder

Specify if Early Onset/Late OnsetSpecify if Early Onset/Late OnsetSpecify With Atypical FeaturesSpecify With Atypical Features

311 Depressive Disorder NOS311 Depressive Disorder NOS

Disruptive Behavior DisordersDisruptive Behavior Disorders 314.xx Attention-Deficit/Hyperactivity Disorder 314.xx Attention-Deficit/Hyperactivity Disorder

● .01 Combined Type .01 Combined Type ● .00 Predominantly Inattentive Type .00 Predominantly Inattentive Type ● .01 Predominantly Hyperactive-Impulsive Type.01 Predominantly Hyperactive-Impulsive Type

314.9 Attention-Deficit/Hyperactivity Disorder NOS314.9 Attention-Deficit/Hyperactivity Disorder NOS

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

313.81 Oppositional Defiant Disorder313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder NOS312.9 Disruptive Behavior Disorder NOS

Substance Abuse/DependenceSubstance Abuse/Dependence 303.90 Alcohol Dependence/305.00 Alcohol Abuse303.90 Alcohol Dependence/305.00 Alcohol Abuse 304.00Amphetamine Dependence/305.70 Amphetamine Abuse304.00Amphetamine Dependence/305.70 Amphetamine Abuse 304.30 Cannabis Dependence/305.20 Cannabis Abuse304.30 Cannabis Dependence/305.20 Cannabis Abuse 304.20 Cocaine Dependence/305.60 Cocaine Abuse304.20 Cocaine Dependence/305.60 Cocaine Abuse 304.50 Hallucinogen Dependence/305.30 Hallucinogen Abuse304.50 Hallucinogen Dependence/305.30 Hallucinogen Abuse 304.60 Inhalant Dependence/305.90 Inhalant Abuse304.60 Inhalant Dependence/305.90 Inhalant Abuse 305.1 Nicotine Dependence305.1 Nicotine Dependence 304.00 Opioid Dependence/305.50 Opioid Abuse304.00 Opioid Dependence/305.50 Opioid Abuse 304.60 Phencyclidine Dependence/305.90 Phencyclidine Abuse304.60 Phencyclidine Dependence/305.90 Phencyclidine Abuse 304.10 Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative, 304.10 Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative,

Hypnotic, or Anxiolytic AbuseHypnotic, or Anxiolytic Abuse 304.80 Polysubstance Dependence304.80 Polysubstance Dependence 304.90 Other (or Unknown) Substance Dependence304.90 Other (or Unknown) Substance Dependence 305.90 Other (or Unknown) Substance Abuse305.90 Other (or Unknown) Substance Abuse

The following specifiers apply to Substance Dependence as noted:The following specifiers apply to Substance Dependence as noted:With Psychological Dependence/Without Psychological DependenceWith Psychological Dependence/Without Psychological DependenceEarly Full Remission/Early Partial Remission/Sustained Full Early Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial Remission In a Contained Environment On Agonist Remission/Sustained Partial Remission In a Contained Environment On Agonist TherapyTherapy

Mental Health Procedural CodesMental Health Procedural Codes

Evaluation & Management (E&M) CodesEvaluation & Management (E&M) Codes

99201 – 99215 New and Established Patient Office 99201 – 99215 New and Established Patient Office VisitsVisits

99241 - 99245 Consultations99241 - 99245 Consultations

99361 - 99362 Case Management Services, Team 99361 - 99362 Case Management Services, Team ConferencesConferences

99371 - 99373 Case Management Services, 99371 - 99373 Case Management Services, TelephonicTelephonic

Mental Health Procedure Mental Health Procedure CodesCodes

90801 - 90802 Psychiatric Diagnostic or Evaluative Interview 90801 - 90802 Psychiatric Diagnostic or Evaluative Interview ProceduresProcedures

90804 - 90829 Psychotherapy90804 - 90829 Psychotherapy90804 - 90815 Office or Other Outpatient Facility90804 - 90815 Office or Other Outpatient Facility90810 - 90815 Interactive Psychotherapy90810 - 90815 Interactive Psychotherapy90816 - 90829 Inpatient Hospital, Partial Hospital 90816 - 90829 Inpatient Hospital, Partial Hospital

or Residential Care Facilityor Residential Care Facility

90845 - 90857 Other Psychotherapy90845 - 90857 Other Psychotherapy

90862 - 90889 Other Psychiatric Services or Procedures90862 - 90889 Other Psychiatric Services or Procedures

Psychiatric Therapeutic ProceduresPsychiatric Therapeutic Procedures

CPT Codes 90804 – 90889CPT Codes 90804 – 90889

Psychotherapy is the treatment for mental Psychotherapy is the treatment for mental illness and behavioral disturbances in which illness and behavioral disturbances in which the clinician establishes a professional contract the clinician establishes a professional contract with the patient and, through definitive with the patient and, through definitive therapeutic communication, attempts to therapeutic communication, attempts to alleviate the emotional disturbances, reverse or alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and change maladaptive patterns of behavior, and encourage personality growth and encourage personality growth and development.development.

E&M Codes and MH CodesE&M Codes and MH Codes

The Evaluation and Management services The Evaluation and Management services should not be reported separately, when should not be reported separately, when reporting codes:reporting codes:

90805, 90807, 90809, 90811, 90813, 90815, 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829.90817, 90819, 90822, 90824, 90827, 90829.

Reimbursement – who can bill?Reimbursement – who can bill?

What are the rules governing who can bill for What are the rules governing who can bill for mental health diagnosis/treatment in your mental health diagnosis/treatment in your state?state?

● Most states accept physicians (MD), clinical Most states accept physicians (MD), clinical psychologists (CP), licensed clinical social psychologists (CP), licensed clinical social workers (LCSW)workers (LCSW)

● However, each State has its own rules and However, each State has its own rules and many will pay for other professionalsmany will pay for other professionals

Coverage IssuesCoverage Issues

A provider should A provider should know what services know what services are covered.are covered.

Services must be Services must be documented and documented and medically necessarymedically necessary in order for payment in order for payment to be made.to be made.

Do you, as a provider, know if all Do you, as a provider, know if all services provided are covered?services provided are covered?

Are you documenting properly, and Are you documenting properly, and what about this “medically what about this “medically necessary” bit?necessary” bit?

How Much are you Paid?How Much are you Paid?

ReimbursementReimbursement● Reductions in reimbursement rates by Reductions in reimbursement rates by

provider typeprovider type● PhysicianPhysician - not discounted- not discounted● Clinical PsychologistClinical Psychologist - discounted- discounted● LCSWLCSW - further discounted- further discounted● OtherOther - discounted if - discounted if

coveredcovered

Reimbursement IssuesReimbursement Issues

E&M codes are limited to physicians, PAs, E&M codes are limited to physicians, PAs, NPs, nursesNPs, nurses

Same is true for 90805, 90807, 90809 codesSame is true for 90805, 90807, 90809 codes

An E&M (992XX) and a therapy (908XX) An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service cannot be billed on the same date of service to most Medicaid programsto most Medicaid programs

Documentation and Coding:Documentation and Coding:Fraud and AbuseFraud and Abuse

Services MUST be medically necessary Services MUST be medically necessary (determined by payers based on a review of (determined by payers based on a review of services billed)services billed)

Music, game, instrument, pet interaction Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other therapies, sing-alongs, arts and crafts, and other similar activities should similar activities should not be billednot be billed as group or as group or individual activities.individual activities.

Services performed by a non-licensed provider Services performed by a non-licensed provider particularly as “incident to” using the PIN of the particularly as “incident to” using the PIN of the licensed providerlicensed provider

Elements of “Incident To”Elements of “Incident To” An integral part of the physician’s professional An integral part of the physician’s professional

serviceservice

Commonly rendered without charge or generally Commonly rendered without charge or generally not itemized separately in the physician’s billnot itemized separately in the physician’s bill

Of a type that are commonly furnished in Of a type that are commonly furnished in physician’s office or clinicphysician’s office or clinic

Furnished under the physician’s direct personal Furnished under the physician’s direct personal supervisionsupervision

Action Steps for Action Steps for Mental Health Coding ImprovementsMental Health Coding Improvements

TT

Questions to AnswerQuestions to Answer

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

What providers are eligible to provide behavioral health What providers are eligible to provide behavioral health services?services?

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

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

What are the guidelines for billing services as “incident What are the guidelines for billing services as “incident to?”to?”

Review Program ServicesReview Program Services

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

Determine if there are additional Determine if there are additional Behavioral/Mental Health Services you Behavioral/Mental Health Services you want to providewant to provide

Review and Modify Encounter FormReview and Modify Encounter Form

Does encounter form include both diagnostic Does encounter form include both diagnostic and procedural codes that would be used for and procedural codes that would be used for behavioral health when delivered by primary behavioral health when delivered by primary care providers? Mental health providers? care providers? Mental health providers?

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

Do diagnostic codes represent all diagnostic Do diagnostic codes represent all diagnostic categories (including those not billed for)?categories (including those not billed for)?

Review and Modify Documentation ProceduresReview and Modify Documentation Procedures

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

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

Are codes entered into database regardless Are codes entered into database regardless of reimbursement?of reimbursement?

Understand State Understand State ProgramProgram and and Provider Provider Coverage IssuesCoverage Issues

Research State Program InformationResearch State Program Information● www.cms.gov (Medicare Regulations)www.cms.gov (Medicare Regulations)● Search by state by Department of Health or Search by state by Department of Health or

Department of Mental Health to find state specific Department of Mental Health to find state specific informationinformation

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

Invite Medicaid Representatives to your Invite Medicaid Representatives to your facility or visit them to present Behavioral facility or visit them to present Behavioral Health Program and clearly understand the Health Program and clearly understand the requirementsrequirements

Determine Reimbursement EstimatesDetermine Reimbursement Estimates

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

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

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

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Common Pitfalls inCommon Pitfalls inCodingCoding

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ICD-9 CM (ICD-9 CM (Clinical ModificationClinical Modification) ) Coding Guidelines Coding Guidelines

Order to list ICD-9 codesOrder to list ICD-9 codes

Coding Order is ImportantCoding Order is Important1.1. Acute Reason patient is being seen Acute Reason patient is being seen

needs to be listed first.needs to be listed first.2.2. Co-morbid diagnosis affecting treatment Co-morbid diagnosis affecting treatment

of principal diagnosis are listed next.of principal diagnosis are listed next.3.3. List all other documented conditions List all other documented conditions

coexisting at the time of the visit that coexisting at the time of the visit that require or affect patient care, treatment or require or affect patient care, treatment or management. Chronic diseases may be management. Chronic diseases may be listed as often as they are treatedlisted as often as they are treated

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ICD-9-CM Coding GuidelinesICD-9-CM Coding Guidelines

DO NOT CODE:DO NOT CODE:● Conditions previously treated that no Conditions previously treated that no

longer exist.longer exist.● Conditions that do not affect treatment Conditions that do not affect treatment

or management at the current visit.or management at the current visit.● Rule-out, suspected, questionable or Rule-out, suspected, questionable or

probable diagnoses.probable diagnoses.

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ICD-9-CM Coding Guidelines ICD-9-CM Coding Guidelines Review of Systems DocumentationReview of Systems Documentation

Cannot say “all other negative”Cannot say “all other negative”Must list pertinent and negative Must list pertinent and negative

findingsfindingsMust have a way to determine which Must have a way to determine which

systems were reviewedsystems were reviewedA check list is acceptableA check list is acceptable

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About Time With the PatientAbout Time With the Patient

Do not base your level of service on Do not base your level of service on time spent with patient.time spent with patient.

Time only comes into play if you are Time only comes into play if you are billing for counseling within an acute billing for counseling within an acute visit or if all you are doing is counselingvisit or if all you are doing is counseling

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Sports PhysicalsSports Physicals

They are not meant to be They are not meant to be comprehensive physicals – their focus comprehensive physicals – their focus is differentis different

Check www.aafp.org for an appropriate Check www.aafp.org for an appropriate formform

You can bill for a complete PE and a You can bill for a complete PE and a sports PE within the same yearsports PE within the same year

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Acute Problems within a Acute Problems within a Comprehensive PhysicalComprehensive Physical

When doing a preventive health visit When doing a preventive health visit (V20.2) and there is a separate health (V20.2) and there is a separate health acute problem – you can list both the acute problem – you can list both the preventive health visit code (first) and the preventive health visit code (first) and the acute visit code (second) – BUT THERE acute visit code (second) – BUT THERE MUST BE ICD-9 CODES THAT JUSTIFY MUST BE ICD-9 CODES THAT JUSTIFY BOTHBOTH

(the billing department must add a (the billing department must add a modifier)modifier)

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Be sure to know the Be sure to know the Reason for the VisitReason for the Visit

P re ve n tiveV is it

A cu teV is it

C o u n se lingV is it

R e a so n fo rV is it

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Late Effects of BurnsLate Effects of Burns

Late effects means the burn has healed. Late effects means the burn has healed. There should not be dressing changes.There should not be dressing changes.

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Counseling VisitsCounseling Visits

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

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ExampleExampleDietary Surveillance & CounselingDietary Surveillance & Counseling

There must be a dietary problem in There must be a dietary problem in order to justify this code.order to justify this code.

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Be Specific with the Be Specific with the codes you usecodes you use

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784.1 Throat Pain784.1 Throat Pain

EXCLUDES:EXCLUDES:● Dysphagia 787.2Dysphagia 787.2● Neck pain 723.1Neck pain 723.1● Sore throat 462Sore throat 462● Chronic 472.1Chronic 472.1

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AGAIN - AboutAGAIN - AboutOver-coding and Under-codingOver-coding and Under-coding

CPT and ICD-9 codes must always CPT and ICD-9 codes must always relaterelate

The first ICD-9 code you use drives the The first ICD-9 code you use drives the relationship to the CPT coderelationship to the CPT code

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Coding Compliance Coding Compliance Audit Audit

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Poor example Poor example incorrect coding for incorrect coding for documentationdocumentation

See Handouts of Completed Note See Handouts of Completed Note Sample 10a Sample 10a (handout 9)(handout 9)

&&Encounter Form 10a Encounter Form 10a (handout 10)(handout 10)

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Analysis of incorrect coding Analysis of incorrect coding for documentationfor documentation

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Coding Audit Cheat Sheet Coding Audit Cheat Sheet Top half of formTop half of form

PATIENT IDENTIFIER____PATIENT IDENTIFIER____10a10aCODING AUDIT CHEAT SHEETCODING AUDIT CHEAT SHEET

TYPE OF SERVICE PROVIDED:TYPE OF SERVICE PROVIDED:Preventive Health – New patientPreventive Health – New patient ____________Preventive Health – Established patientPreventive Health – Established patient ____________Counseling Services– No Physical ComplaintCounseling Services– No Physical Complaint

Is time recorded in chart? Is time recorded in chart? YES _____YES _____NO _____NO _____Is a counseling code used? Is a counseling code used? YES _____ NO _____YES _____ NO _____

Evaluation / Management Visit: where counseling determines timeEvaluation / Management Visit: where counseling determines timeIs the total time of the visit recorded Is the total time of the visit recorded YES _____YES _____NO _____ NO _____ Is the time spent in counseling recorded Is the time spent in counseling recorded YES _____ NO _____YES _____ NO _____Is a counseling code used? Is a counseling code used? YES _____ NO _____YES _____ NO _____

Evaluation / Management Visit –Evaluation / Management Visit – NEW PATIENTNEW PATIENTEvaluation / Management Visit – ESTABLISHED PATIENTEvaluation / Management Visit – ESTABLISHED PATIENT

CPT & ICD-9 CODES USEDCPT & ICD-9 CODES USED

CPT CODES: CPT CODES: 9920399203 ICDE-9 CODES: ICDE-9 CODES: 625.3625.3 DO THE CPT/ICD-9 CODESDO THE CPT/ICD-9 CODESCORRELATE?CORRELATE?

YES __YES __XX___NO ___NO ______ ______

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Coding Audit Cheat SheetCoding Audit Cheat SheetBottom Half of FormBottom Half of Form

HISTORY AND EXAMINATIONHISTORY AND EXAMINATION

New New 9920199201 9920299202 9920399203 9920499204 9920599205 EstablishedEstablished 9921199211 9921299212 9921399213 9921499214 9921599215

HPIHPI 00 11 11 44 44 ROSROS 00 00 11 22 1010 PFSHPFSH 00 00 00 11 22 EXAMEXAM 00 11 44 55 8 8

CHART AUDIT LEVELS FOR E/M VISITSCHART AUDIT LEVELS FOR E/M VISITS

HPI, ROS, PFSHHPI, ROS, PFSH 33 NEW PATIENT LEVELNEW PATIENT LEVEL 22

Lowest level supports levelLowest level supports level

EXAMINATIONEXAMINATION 22 ESTABLISHED PT LEVEL ____ESTABLISHED PT LEVEL ____

2 of 3 or middle level supports level2 of 3 or middle level supports level

MEDICAL DECISION MAKINGMEDICAL DECISION MAKING 33

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Medical Decision MakingMedical Decision Making Section I: Section I: Diagnosis or Management of ProblemsDiagnosis or Management of Problems

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215One self-limited or minor problem

Two or more self-limited or minor problems

-One stable chronic condition-Acute uncomplicated illness

One or more chronic illnesses with complicationsTwo or more stable chronic conditionsUndiagnosed new problem w/uncertain prognosesAcute illness with systemic symptomsAcute complicated injury

One or more chronic illness with severe complicationsAcute or chronic illness or injury that is life or limb threateningAbrupt change in neurologic status

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Medical Decision Making Medical Decision Making Section II: Diagnostic ProceduresSection II: Diagnostic Procedures

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

LabX-rayEKGUAUltrasound, etc.VenipunctureKOH

Physiologic tests not under stressPulmonary FunctionBarium EnemaArterial punctureSkin biopsies

Physiologic tests under stress-cardiac stress testsDiagnostic endoscopies with no risk factorsDeep needle or incisional biopsyObtained fluid from bodyCardiovascular imaging with contrast

Cardiovascular imaging with contrastInvasive diagnostic testsCardiac Electrophysiological tests Diagnostic endoscopies with identified risk factorsDiscography

Other levels of Diagnostic procedures do not usually apply to SBHC, but you only Other levels of Diagnostic procedures do not usually apply to SBHC, but you only need to have 2 of the 3 areas of medical decision making to agree.need to have 2 of the 3 areas of medical decision making to agree.

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Medical Decision Making Medical Decision Making Section III: Treatment or Management OptionsSection III: Treatment or Management Options

99201 99202 99203 99204 99205

99211 99212 99213 99214 99215

RestGarglesElastic bandagesDressings

OTCsMinor surgeryPTOTIVs without additives

Minor surgery with risk factorsElective major surgery—no risk factorsPrescription drug managementIV fluids with additivesClosed facture or dislocation treatment w/o manipulationTherapeutic nuclear medicine

Elective Surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug treatment requiring intensive monitoringDecision not to resuscitate or de-escalate care because of poor prognosis

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Unfortunately – Because of this Unfortunately – Because of this documentation/coding error - you documentation/coding error - you

will not get paid for this visit.will not get paid for this visit.This is why it is very important to This is why it is very important to

verify that verify that charting supports charting supports

all levels of coding decision all levels of coding decision making.making.

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Questions & AnswersQuestions & Answers

Documents

Coding 101 The Partnership TOT, September 22, 2008 Taken from “Beginning Coding”, “Intermediate Coding”, and “I Hate Coding” by Dianne Demers