Coding 2013 Opportunities and

Challenges

Richard H. Tuck, MD, FAAP

© Richard H. Tuck, MD 1/1/12

Disclosure I have financial relationships or interests with proprietary

entities producing health care goods or services related to the content of this CME activity. I am Consulting Editor of Pediatric Coding Alert for Eli Health Care.

I serve on the speakers bureau for Sanofi Pasteur. My content will not include discussion/

reference of commercial products or services. I do not intend to discuss an unapproved/

investigative use of commercial products/devices.

IMPORTANCE OF ACCURATE APPROPRIATE CODING

INCREASED PAYMENT

DECREASED LIABILITY

IMPROVED INFORMATION FLOW

What’s New for 2013? CODES - New CPT/ICD Codes VALUE- RBRVS – New RVU’s and CF PAYER PAYMENT-

AAP Private Sector Advocacy Program State Pediatric Councils National Class Action Law Suits

PATIENTS- Covered Benefit Consumer Driven Health Care

YOUR CONTRACT- Pay for Performance – Clinical Integration, ACOs

CODING CHANGES 2013

2013 CPT Changes Revision inclusion/ exclusion

provider/professional type instructions Observation services assigned typical times Interfacility transport supervision care codes Neonatal/pediatric critical care guideline changes Complex care and transitional care services codes Vaccine code changes New psychotherapy codes

Pharmacologic management revised

2013 CPT Changes

Revisions to cardiology section Allergy instructions and codes revised New codes for pediatric polysomnography Infusion and IV push examples Revision of vision screening code

“Other Qualified Health Care Professional”

Almost all CPT code descriptors and specific instructions revised to consistently reflect the inclusion/exclusion of provider type

Also revised to consistently reflect inclusion of a “qualified health care professional” when word “physician” is included

Observation or Inpatient Care Services (Including Admission and Discharge Services)

Code 99234 99235 99236

History Detailed or Comprehensive

Comprehensive Comprehensive

Exam Detailed or Comprehensive

Comprehensive Comprehensive

Decision Making

Straightfd or Low Complexity

Mod Complexity

High Complexity

Time/ Floor 40 50 55 Key # 3 of 3 3 of 3 3 of 3

Non Face to Face Physician

99444 Online evaluation and management service provided by a physician to an established patient or guardian, health care provider not originating from a related E/M service in previous 7 days, using the internet of similar electronic communications network

Pediatric Critical Care Patient Transport

To report the control physician non face-to-face suprervision of interfacility transport of critically ill/injured patient < 24 months of age

Includes two way communication prior to transport, during transport with team, not with facility

Time from first contact with team, ends when care handed over to receiving facility team

Pediatric Critical Care Patient Transport

99485 Supervision by control physician of interfacility transport, < 24 months of age, first 30 minutes (do not report <15 minutes)

99486 Each additional 30 minutes

99288 Over 24 months of age, or any age if not critically ill or injured

Neonatal Intensive Care and Pediatric/Neonatal Critical Care Services

99468,99469 Neonatal/Pediatric Critical Care Reported by a single individual physician, per hospital stay, in a given facility If readmitted, report 99469 for first day of readmission 99468 reported in addition to 99464 (delivery attendance), 99465 (resuscitation)

Pediatric/Neonatal Critical Care Services

Two separate institutions: Referring individual physician to use time-based critical care codes (99291,99292)

Receiving physician to use initial day critical care codes if child <6 years if age

If transferred to lower level of care different physician same facility, transferring physician does not report per day critical care, receiving physician report subsequent intensive or hospital care

Pediatric/Neonatal Critical Care Services Neonate or infant becomes critically ill day when

intensive care services, hospital, or nl newborn services have been performed. Different physician, different group

Transferring reports one service only (critical, intensive, hospital care, nl newborn)

Receiving reports initial or subsequent critical care Newborn becomes critically ill same day received nl

nb care, same physician/group reports initial critical care with -25 modifier on critical care code

Initial/Continuing Intensive Care

Neonate becomes critical after seen as intensive same day, to different group

Transferring physician reports time based critical care or intensive care, not both

Receiving physician reports initial or subsequent critical care based on age

Neonate becomes critical after intensive same day same group, report either intensive or critical care

More CPT 2013 Changes

Pneumocentesis and thoracentesis codes (32420-32422) deleted

(32554-32557) replaced, designating same procedures performed with or w/o imaging

Laboratory 87910, 87912, 87901 – New tests using nucleic

acid probe for detection for CMV, Hepatitis B

Vaccines, Toxoids

90655 – 90660 Influenza vaccines trivalent (current vaccines)

90672, 90685 – 90688 Influenza vaccines quadrivalent (FDA approval pending)

90701 deleted (DTP - whole cell pertussis) 90718 deleted (Td)

Psychiatric Services or Procedures 90863 Pharmacologic

management, including prescription review of medication, when performed with psychotherapy services (Use in conjunction with 908P10, P20, P30) Can also use with appropriate E/M codes Do not double count time

90862 deleted Pharmacologic management with no more than minimal psychotherapy

Sleep Services

All sleep services (95800 – 95811) include recording, interpretation, and report

-52 modifier if , 6 or 7 hours recording (code specific) or if <4 nap opportunities

Sleep Services

95808 Polysomnography - any age 95810 age > 6 years 95811 age > 6 years (with initiation of ventilation) 95782 < 6 years 95783 < 6 years (with initiation of ventilation)

Ocular Screening

99174 Instrument based ocular screening (eg photoscreening, automated-refraction, bilateral)

Do not report in conjunction with other vision screening 99172 automated or semiautomated 99173 screening test, quantitative, bilateral

Allergy Testing

95010 Percutaneous tests (scratch, puncture, prick) 95015 Intracutaenous (intradermal) 95017 Any combination percutaneous and

intracutaneous, with venoms 95018 Any combination percutaneous and

intracutaneous, with drugs or biologicals

Allergy Testing

95076 Ingestion challenge test, initial 120 minutes of testing

95079 Each additional 60 minutes of testing

Complex Care Coordination Services

Provided by physicians, other QHCP, and clinical staff Involve care plan directed by physician or other QHCP Address coordination of care by multiple disciplines

and community agencies Address services for medical conditions, psychosocial

needs, and activities of daily living

Complex Care Coordination Services

90487 Complex chronic care coordination services; first hour of clinical staff time, directed by physician or other QHCP, no f to f visit, per calender month

90488 with one face-to-face visit, per calender month

90489 each additional 30 minutes, per calender month

Transitional Care Management Services (TCM)

Established patient requiring mod or high complexity decision making during transitions from inpatient hospital setting, partial hospital, observation, or skilled/nursing facility to patient’s community setting (home, domiciliary,assisted living)

TCM commences on date of discharge Continues for next 29 days

Transitional Care Management Services (TCM)

99495 Transitional Care Management with: Communication with pt or caregiver within 2 business days of discharge Minimum of moderate complexity decision making Face to face visit within 14 calender days of discharge

99496 Transitional Care Management with: As above but requiring: high complexity MDM Face to face visit within 7 calender days of discharge

Increased RVU’s 2012 Preventive Medicine

New % Increase Est % Increase 99381 26% 99391 34% 99382 18% 99392 26% 99383 25% 99393 26% 99384 31% 99394 25%

Increased RVU’s 2012 Newborn Care

% Increase 99460 Initial NB 64% 99462 Subs NB 35% 99463 SD Ad/Disch 42%

2013 ICD Changes ?

NONE ! Freeze on ICD-9 and ICD-10 changes in

anticipation of ICD-10 implementation in October 2013, now October 1, 2014

ICD-10-CM

Will become effective October 1, 2014 – NO EXCEPTIONS if you are a covered entity under

HIPAA. – Currently there is a freeze on new ICD-9-CM and

ICD-10-CM codes to prepare for the changeover.

AAP webinar February 9, 2012, addresses ICD-10-CM.

ICD-10

A CHANGE FOR THE BETTER !

Value to Providers

More accurately reflects the acuity of the patient population

More accurately reflects application of advances in medical knowledge

Improved visibility into population health/risks Better defined and automated referrals and approvals More detail for preauthorization medical review

Vaccine ICD-10 Coding

ICD-10 effective October 1, 2014 Preventive Care V20.2 crosswalks: Z00.129 w/o abnl findings

Z00.121 with abnl findings Vaccine product V codes all crosswalk to one ICD-10

code: Z23, encounter for immunization Vaccination not carried out (V64.00- V64.09) crosswalk

with Z28.20-Z28.9 codes

Transition: What you can do now?

Communicate the implementation process with everyone! Look at the current systems/resources that exist Determine workflow and process changes Review your EMR/HER programs to verify they are ICD-

10-CM ready and what steps you have to take to update If you don’t have an EMR or billing program look in to one

that supports ICD-10-CM – Capability to run both codes a bonus

Look at costs of the change-over and start planning now

Transition: What you can do now?

Encourage your physicians to document and use more specific codes – Especially those who tend to use unspecified codes or

whose documentation leads to an “unspecified” code Work with those physicians on their documentation and

in areas where you know more documentation is needed (e.g. Otitis Media)

Remember that all HIPAA covered entities are required to adhere to the transition to ICD-10-CM – So do you!

ICD-10-CM +

Leverage your investment Move beyond mere compliance to achieve

strategic advantage

ICD-10 GEMs

General Equivalence Mappings Tool for converting ICD-9-CM databases to ICD-

10-CM or ICD-10-PCS Backward and forward mapping Move to coding books and encoder systems

October 1, 2014

AAP ICD-10 Crosswalks

Immunizations 2012 - 2013

How are you doing ? Challenges ? Successes !

Immunizations

Bill and Document ALL: – E/M Visit

» Office Visit, Preventive Medicine – Immunization Administration

» 90471 – 90474 » 90460 – 90461 in 2011 (90465-90468 - deleted)

– Vaccine/Toxoid » 90476 – 90749

Link to ICD Diagnoses – V20.2 Well Child – CSHCN Diagnosis – + Specific Vaccine V Codes (V06.8- combination vaccines)

EXISTING CPT CODES 2000 Vaccine Administration 90471 Immunization administration (includes percutaneous,

intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)

90472 each additional vaccine (single or combination

vaccine/toxoid) (List separately in addition to code for primary procedure)

90473 Immunization administration by intranasal or oral route;

one vaccine (single or combination vaccine/toxoid) 90474 each additional vaccine (single or combination

vaccine/toxoid) (List separately in addition to code for primary procedure)

CPT 2011 Effective January 1, 2011

NEW Pediatric Immunization Administration Codes

90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

90461 Each additional vaccine/toxoid component (List separately in addition to code for primary procedure)

CPT 2011 Effective January 1, 2011

Immunization Administration What is a vaccine component?

A component refers to antigen in a vaccine that prevents disease (s) caused by one organism

Combination vaccines contain multiple vaccine components – IPV one component – MMR three components – DTaP-Hib-IPV five components

Counseling Counseling:

Giving the parent the VIS sheet Discussing concerns, pros and cons Management of any reactions Dosing acetaminophen/ ibuprophen Answering any other questions

Documentation is a must! “Counseled on vaccines and vaccine components”

Other Qualified Health Care Professional CPT 2012 now defines this as

“A ‘physician or other qualified health care professional’ is an individual who by education, training, licensure/regulation, and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports a professional service. These professionals are distinct from ‘clinical staff.’

“A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service. Other policies may also affect who may report specified services.”

Other Qualified Health Care Professional 2012

What does that mean? – Clinical staff (eg, RNs, LPNs) can no longer have

codes 90460–90461 (immunization administration) reported to represent when they counsel patients or parents/guardians on vaccines.

– If clinical staff performs counseling, you must report a code from the 90471–90474 series as appropriate.

CPT 2011 Effective January 1, 2011

NEW Pediatric Immunization Administration Codes

To report a single component vaccine, use 90460 To report a multiple component vaccine

(combination vaccine), use 90460 for the first component, and 90461 for each additional component in the combination vaccine

Example: DTaP-Hib-IPV vaccine: After January 1,2011: 90460, 90461 X 4

Link combination vaccines to V06.8

Vaccine Administration RVUs

Values - Existing codes RVU 2012 medicare RVU 2012 medicare

– 90471 – 0.71/ $24.17 90472 – 0.35/ $ 11.91 – 90473 – 0.65/ $22.12 90474 – 0.34/ $ 11.57

Values - New codes – 90460 – 0.72/ $24.51 90461 – 0.37/ $12.59

CPT 2012 Effective January 1, 2011

NEW Pediatric Immunization Administration Codes

Payment comparison PENTACEL® Dtap/IPV/Hib 90698 ICD V06.8

Old codes: – 90471 $24 – 90471, 90472 X 2 $48 for 3 separate vaccines

New codes:

– 90460, 90461 X 4 $77

1/1/2011 IA Summary 90460 – 90461 Implemented 90465 – 90468 Deleted 90471 – 90474 Unchanged

Use when no counseling is provided Patient ≥ 19 years of age Provider not “other qualified health care professional”

In addition to IA , code vaccine toxoid code 90476 - 90749

CDC Update on Vaccine Storage

Interim Guidance 40,000 VFC sites Studies showing problems with storage and

handling of VFC vaccines Providers are responsible for losses AAP response pending related to increased costs

of vaccine delivery

CDC Requirements Increased documentation

– Recording temperature 2X per day – Recording each morning min and max temps over previous 24

hours Replace glass thermometers with data logging monitors

with thermal buffer/ 24/7 recording Elimination combination refrigerator/freezers Certification of temp monitoring devices

Phone enabled monitor to report “temperature excursion”

CDC Requirements

Domestic refrigerator only still acceptable Specific storage recommendations Vaccines 2-3 inches from walls Away from direct air flow Water bottles to mitigate temp variation Avoid top shelf

QUESTIONS ? STUMP THE CODER !

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November 27th, 2012

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November 29th, 2012

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December 12th, 2012

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