Coding, Documentation, and Data Management Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs

Coding, Documentation, and Coding, Documentation, and Data Management Data Management

Kyle C. Dennis, Ph.D.,Kyle C. Dennis, Ph.D.,

Deputy Director, Audiology & Deputy Director, Audiology & Speech Pathology ServiceSpeech Pathology Service

Department of Veterans AffairsDepartment of Veterans Affairs

Session ObjectivesSession Objectives

Understand basic code systems and Understand basic code systems and development of codesdevelopment of codes

Understand basic organization and Understand basic organization and principles of procedure and disease codingprinciples of procedure and disease coding

Understand basic principles of coding and Understand basic principles of coding and billingbilling

Understand basic principles of Understand basic principles of documentationdocumentation

Topics for DiscussionTopics for Discussion

Coding systemsCoding systemsProcedure codesProcedure codesDisease codesDisease codesCoding, billing, and complianceCoding, billing, and complianceDocumentationDocumentationReferral guidelines and service Referral guidelines and service

agreementsagreements

How are codes used?How are codes used?

Revenue generation (reimbursement)Revenue generation (reimbursement) Documentation of servicesDocumentation of services Workload and utilizationWorkload and utilization ProductivityProductivity Cost analysisCost analysis Provider profiles (privileging)Provider profiles (privileging) Analysis, health research, and trendingAnalysis, health research, and trending

Why is coding compliance so Why is coding compliance so important in data management?important in data management?

Critical to workload and data captureCritical to workload and data captureCritical to resource allocation Critical to resource allocation Critical for health care planningCritical for health care planningCritical to third-party (insurance) Critical to third-party (insurance)

reimbursement reimbursement Must conform to uniform national Must conform to uniform national

standards (CMS compliance)standards (CMS compliance)

……and more importantlyand more importantly

Demonstrates adherence to Demonstrates adherence to community standards of care community standards of care

Demonstrates accountability to Demonstrates accountability to patients and stakeholderspatients and stakeholders

Demonstrates to stakeholders that Demonstrates to stakeholders that critical services and special critical services and special programs are maintainedprograms are maintained

Basic Management QuestionsBasic Management Questions

How much work did my clinic do?How much work did my clinic do?What did it cost?What did it cost?Can I bill for it?Can I bill for it?If I can’t bill for it, does it affect my If I can’t bill for it, does it affect my

costs and productivity?costs and productivity?How much revenue did I generate?How much revenue did I generate?Is my clinic a “value-added” service?Is my clinic a “value-added” service?Is my clinic efficient?Is my clinic efficient?

Basic Data ElementsBasic Data Elements

Patient demographics (name, SSN)Patient demographics (name, SSN)Diagnoses, conditions, symptoms, or Diagnoses, conditions, symptoms, or

problemsproblemsProcedures or servicesProcedures or servicesProviderProvider Successful capture of encounter data Successful capture of encounter data

requires these basic elements.requires these basic elements.

Basic Data FlowBasic Data Flow

AppointmentAppointmentVisitVisitEncounterEncounterEncounter dataEncounter datadatabase=management database=management

reports, analyses, and trendsreports, analyses, and trendsEncounter dataEncounter databilling billing

system=reasonable charges=revenuesystem=reasonable charges=revenueImportant…accurate coding is essential Important…accurate coding is essential

because data management systems are because data management systems are linked. It all starts with the basic data linked. It all starts with the basic data elements.elements.

The Manager’s TaskThe Manager’s Task

Use various data systems to optimize workload, Use various data systems to optimize workload, efficiency, utilization, costs, and revenue generationefficiency, utilization, costs, and revenue generation

Benefits to the organizationBenefits to the organization data-driven decision makingdata-driven decision making maximized valuemaximized value quality improvementquality improvement accountabilityaccountability justification of resourcesjustification of resources tracking of utilization, costs, and health care trendstracking of utilization, costs, and health care trends predictable, consistent health care deliverypredictable, consistent health care delivery

Coding SystemsCoding Systems

Topics for DiscussionTopics for Discussion

Coding SystemsCoding SystemsProcedure Codes Procedure Codes Disease CodesDisease CodesCoding and BillingCoding and BillingDocumentationDocumentation

Procedure Coding SystemsProcedure Coding Systems

Healthcare Common Procedure Coding Healthcare Common Procedure Coding SystemSystem (HCPCS) (HCPCS)

Current Procedural TerminologyCurrent Procedural Terminology (CPT) (CPT)HCPCS Level II (National or HCPCS)HCPCS Level II (National or HCPCS)ICD-9 PCSICD-9 PCSFuture: ICD-10 and ICD-10 PCSFuture: ICD-10 and ICD-10 PCS

Disease CodingDisease Coding

International Classification of Diseases, International Classification of Diseases, Ninth Edition, with Clinical ModificationsNinth Edition, with Clinical Modifications (ICD-9-CM)(ICD-9-CM)

Future: International Classification of Future: International Classification of Diseases, Tenth EditionDiseases, Tenth Edition (ICD-10-CM) (ICD-10-CM)

Future Code SystemsFuture Code Systems

ICD-10-CMICD-10-CMDeveloped by World Health OrganizationDeveloped by World Health OrganizationClinical modification for U.S. developed by Clinical modification for U.S. developed by

National Center for Health StatisticsNational Center for Health StatisticsICD-10 PCS developed by 3M under ICD-10 PCS developed by 3M under

contract from CMScontract from CMSHIPAA mandates universal code system. HIPAA mandates universal code system.

ICD-10-CMICD-10-CM

Ear and hearing problems found in Ear and hearing problems found in Chapter 8Chapter 8

More descriptive than ICD-9-CMMore descriptive than ICD-9-CMExamples:Examples:

H90.3--bilateral SNHLH90.3--bilateral SNHL H90.4--unilateral SNHL with unrestricted H90.4--unilateral SNHL with unrestricted

hearing on contralateral sidehearing on contralateral side

ICD-10 PCSICD-10 PCS

Greatly expands procedures codesGreatly expands procedures codesNot proprietaryNot proprietaryExample: Pure tone audiometry-9C03Z1CExample: Pure tone audiometry-9C03Z1C

9=Rehabilitation and Diagnostic Audiology9=Rehabilitation and Diagnostic Audiology C=assessmentC=assessment 03=test method (pure audiometry)03=test method (pure audiometry) Z=body system (none)Z=body system (none) 1=equipment (audiometer)1=equipment (audiometer) C=qualifier (individual)C=qualifier (individual)

HCPCS CodesHCPCS Codes

Level I--Level I--Current Procedural TerminologyCurrent Procedural Terminology (CPT-4)(CPT-4)

Level II--National codesLevel II--National codesLevel III-local codes used by Medicare Level III-local codes used by Medicare

intermediaries, no longer usedintermediaries, no longer usedModifiers for Level I and Level IIModifiers for Level I and Level II

CPT CodesCPT Codes

Copyrighted and published by AMACopyrighted and published by AMAFive digit codes (e.g. 99211)Five digit codes (e.g. 99211)Revised annually by AMARevised annually by AMADescribes physician and non-physician Describes physician and non-physician

services by specialtyservices by specialtyComplexity- or time-basedComplexity- or time-basedIncludes modifiersIncludes modifiers

Organization of CPT CodesOrganization of CPT Codes

Evaluation & Management (99201-99499)Evaluation & Management (99201-99499) Anesthesiology (00100-01999, 99100-99140)Anesthesiology (00100-01999, 99100-99140) Surgery (10040-69990)Surgery (10040-69990) Radiology (70010-79999)Radiology (70010-79999) Pathology and Laboratory (80049-89399)Pathology and Laboratory (80049-89399) Medicine (90281-99199)Medicine (90281-99199) Miscellaneous Services (99000-99090)Miscellaneous Services (99000-99090) CPT Modifiers (Appendix A)CPT Modifiers (Appendix A)

Categories of CPT CodesCategories of CPT Codes

Category I--procedures and services Category I--procedures and services (5 digits) (5 digits)

Category II--performance Category II--performance measurement (4 digits followed by a measurement (4 digits followed by a letter)letter)

Category III--temporary codes (4 Category III--temporary codes (4 digits followed by a letter)digits followed by a letter)

HCPCS Level II (National) CodesHCPCS Level II (National) Codes

Supplemental codesSupplemental codesUpdated annually by CMSUpdated annually by CMSDesignated by letter and four digits (e.g. Designated by letter and four digits (e.g.

V5020)V5020)Ambulance services, dental services, Ambulance services, dental services,

durable medical devices, drugs and durable medical devices, drugs and injections, home services, non-covered injections, home services, non-covered services, temporary and experimental codesservices, temporary and experimental codes

What is New for 2003?What is New for 2003?

New New Evaluation and TherapeuticEvaluation and Therapeutic Section in the Otolaryngology Section in the Otolaryngology Section (92500-series)Section (92500-series)

Cochlear implant codesCochlear implant codesMajor changes for Speech PathologyMajor changes for Speech PathologyNew unlisted ENT service code New unlisted ENT service code

(92700)(92700)

How are CPT Codes Developed?How are CPT Codes Developed?

Developed and copyrighted by AMADeveloped and copyrighted by AMACPT Editorial PanelCPT Editorial Panel--16-member panel --16-member panel

meets quarterly to revise, update or meets quarterly to revise, update or modify CPT codesmodify CPT codes

Health Care Professionals Advisory Health Care Professionals Advisory Committee (HCPAC)Committee (HCPAC)--14-member non---14-member non-physician advisory panel. ASHA physician advisory panel. ASHA represents Audiology and Speech represents Audiology and Speech Pathology with AAA as an observerPathology with AAA as an observer


Resource-based Relative Value System Resource-based Relative Value System Update Committee (RUC)Update Committee (RUC)--29-member --29-member panel assigns reimbursement valuepanel assigns reimbursement value

RUC HCPAC Review BoardRUC HCPAC Review Board----recommends reimbursement for non-recommends reimbursement for non-physician codesphysician codes

Practice Expense Advisory Committee Practice Expense Advisory Committee (PEAC)(PEAC)--being phased out--being phased out


Application to Editorial Panel--must be Application to Editorial Panel--must be FDA approved, proven benefit in peer-FDA approved, proven benefit in peer-reviewed literature, widely used, reviewed literature, widely used, standard of care (category I codes)standard of care (category I codes)

Application sent to RUC or RUC HCPAC Application sent to RUC or RUC HCPAC for review and value determinationfor review and value determination

CMS generally follows AMA CMS generally follows AMA recommendationsrecommendations

Calculating RVUCalculating RVU

Physician work (55%)Physician work (55%)Practice expense (42%)Practice expense (42%)Medical liability insurance (3%)Medical liability insurance (3%)RUC determines only the physician RUC determines only the physician

work and practice expenseswork and practice expensesGlobal RVU x Medicare conversion Global RVU x Medicare conversion

factor=dollar reimbursement valuefactor=dollar reimbursement value

Practice ExpensesPractice Expenses

Most Audiology procedures do not Most Audiology procedures do not involve physician work.involve physician work.

Resource-based relative values Resource-based relative values (RBRVU) include practice expenses (RBRVU) include practice expenses (e.g. clinic labor, equipment, supplies).(e.g. clinic labor, equipment, supplies).

Sources of data: Sources of data: Socioeconomic Socioeconomic Monitoring SurveyMonitoring Survey (SMS) and Clinical (SMS) and Clinical Practice Expert Panel (CPEP)Practice Expert Panel (CPEP)

Practice ExpensesPractice Expenses

SMS data is used to calculate physician SMS data is used to calculate physician practice expense per hour (PE/HR)practice expense per hour (PE/HR)

SMS includes clinical staff time but SMS includes clinical staff time but does not include independent does not include independent audiologists.audiologists.

CMS created “zero work pool”, now CMS created “zero work pool”, now called the Non-physician Work Pool called the Non-physician Work Pool (NPWP)(NPWP)

Practice Expense DataPractice Expense Data

Where do Audiology practice expenses Where do Audiology practice expenses come from?come from?

All physician PE/HR average (SMS) and All physician PE/HR average (SMS) and clinical staff time (CPEP) for procedureclinical staff time (CPEP) for procedure

CMS calculates an expense pool (e.g. CMS calculates an expense pool (e.g. clinical labor) using “all-physician” PE/HR clinical labor) using “all-physician” PE/HR and the CPEP average clinical staff timeand the CPEP average clinical staff time

Data may not be accurate for Data may not be accurate for audiologists.audiologists.

How Does this Affect How Does this Affect Audiologists?Audiologists?

70% of Audiology codes are in the NPWP70% of Audiology codes are in the NPWP90.6% of Audiology revenue comes from 90.6% of Audiology revenue comes from

NPWP, highest of any clinical specialtyNPWP, highest of any clinical specialtyNPWP does not accurately reflect true NPWP does not accurately reflect true

practice expensespractice expensesOptions: obtain survey data or continue Options: obtain survey data or continue

to use physician datato use physician data

Pros and ConsPros and Cons

Are audiologist practice expenses more Are audiologist practice expenses more than physician expenses?than physician expenses?

All-physician average: $69.00 per hourAll-physician average: $69.00 per hourENT: $105.70 per hourENT: $105.70 per hourMany physician specialties are included in Many physician specialties are included in

NPWP (e.g. oncology, radiology, internal NPWP (e.g. oncology, radiology, internal medicine, cardiology)medicine, cardiology)

If some physician groups leave the NPWP, If some physician groups leave the NPWP, the remaining groups will be paid less.the remaining groups will be paid less.

Professional & TechnicalProfessional & Technical

Codes may not have physician work valueCodes may not have physician work valueSome codes have technical (TC) and Some codes have technical (TC) and

professional (26) components.professional (26) components.Professional component=physician work Professional component=physician work

(May be billed by audiologists.)(May be billed by audiologists.)Technical component=practice expenseTechnical component=practice expenseMost Audiology codes do not have Most Audiology codes do not have

physician work.physician work.

RVU Example 1--92585-TCRVU Example 1--92585-TC

Technical procedure without Technical procedure without interpretationinterpretation

Physician work--0.0Physician work--0.0Practice expense--1.18Practice expense--1.18Malpractice--.10Malpractice--.10Non-facility RVU--1.26Non-facility RVU--1.26Medicare fee (unadjusted)--$44.28Medicare fee (unadjusted)--$44.28

RVU Example 2--92585-26RVU Example 2--92585-26

Professional componentProfessional componentPhysician work--0.50Physician work--0.50Practice expense--.22Practice expense--.22Malpractice--.02Malpractice--.02Non-facility RVU--.74Non-facility RVU--.74Medicare fee (unadjusted)--$25.60Medicare fee (unadjusted)--$25.60Notice how small the professional fee is Notice how small the professional fee is

compared the technical fee.compared the technical fee.

RVU Example 3--92585 GlobalRVU Example 3--92585 Global

Physician work--.50Physician work--.50Practice expense--2.06Practice expense--2.06Malpractice--.14Malpractice--.14Non-facility RVU--2.70Non-facility RVU--2.70Medicare fee (unadjusted)--$93.40Medicare fee (unadjusted)--$93.40Global can be billed by audiologists.Global can be billed by audiologists.

Complexity-based CodesComplexity-based Codes

Unless otherwise specified, procedures Unless otherwise specified, procedures are based on are based on complexitycomplexity

Enter Enter oneone code per procedure code per procedure regardless regardless of time spentof time spent

Most CPT codes are complexity-based.Most CPT codes are complexity-based.

Time-based CodesTime-based Codes

Time period is specified (e.g. 15 minutes)Time period is specified (e.g. 15 minutes)Enter one code for each time periodEnter one code for each time periodTotal volume=total timeTotal volume=total timeExample: 2 units=30 minutes for a 15-Example: 2 units=30 minutes for a 15-

minute procedureminute procedureFew Audiology codes are time-based.Few Audiology codes are time-based.Time must be documented.Time must be documented.

Audiology ServicesAudiology Services

CPT codes in the 92500-seriesCPT codes in the 92500-seriesTechnical and professional servicesTechnical and professional servicesDo not require supervision by a physicianDo not require supervision by a physicianPerformed by qualified audiologistsPerformed by qualified audiologistsMust be ordered by a physician to be Must be ordered by a physician to be

billed.billed.

General Purpose CodesGeneral Purpose Codes

92506--evaluation of auditory processing 92506--evaluation of auditory processing and/or aural rehabilitation statusand/or aural rehabilitation status

92507--treatment of auditory processing 92507--treatment of auditory processing disorder (includes aural rehabilitation)disorder (includes aural rehabilitation)

92508--group treatment92508--group treatmentOften used (and abused) for hearing Often used (and abused) for hearing

evaluation and treatment, not elsewhere evaluation and treatment, not elsewhere classifiedclassified

Audiology Treatment CodesAudiology Treatment Codes

Audiologists cannot be reimbursed for Audiologists cannot be reimbursed for treatmenttreatment services under Medicare services under Medicare 69200--foreign body removal69200--foreign body removal 69210--cerumen management69210--cerumen management 97112--vestibular rehabilitation97112--vestibular rehabilitation

Implant ServicesImplant Services

Cochlear implant evaluation: Use Cochlear implant evaluation: Use audiological assessment codesaudiological assessment codes

Post-op analysis and fitting:Post-op analysis and fitting: 92601--Diagnostic analysis of CI, <7 yoa92601--Diagnostic analysis of CI, <7 yoa 92602--Subsequent programming, < 7 yoa92602--Subsequent programming, < 7 yoa 92603--Diagnostic analysis of CI, >7 yoa92603--Diagnostic analysis of CI, >7 yoa 92604--Subsequent programming, > 7 yoa92604--Subsequent programming, > 7 yoa

Billable as diagnostic servicesBillable as diagnostic servicesCI Rehab (treatment)--92510 or 92507?CI Rehab (treatment)--92510 or 92507?

Implant ServicesImplant Services

No specific codes for brainstem No specific codes for brainstem implantsimplants

Use codes for cochlear implantUse codes for cochlear implantWith diagnosis of vestibular With diagnosis of vestibular

schwannoma (225.1) or NF-2 schwannoma (225.1) or NF-2 (237.72)(237.72)

Vestibular Function TestsVestibular Function Tests

With electrical recordingWith electrical recording 92541--spontaneous nystagmus test92541--spontaneous nystagmus test 92542--positional nystagmus test92542--positional nystagmus test 92543--caloric vestibular test, each irrigation92543--caloric vestibular test, each irrigation 92544--optokinetic nystagmus test92544--optokinetic nystagmus test 92545--oscillating tracking test (pursuit)92545--oscillating tracking test (pursuit) 92546--sinusoidal vertical axis rotation test92546--sinusoidal vertical axis rotation test


92547--use of vertical channel recording92547--use of vertical channel recordingAdd-on codeAdd-on code--usually limited to 92541 --usually limited to 92541

and 92542and 92542No specific code for saccades (use No specific code for saccades (use

92700)92700)


Observation without electrical recordingObservation without electrical recordingNo reimbursement valueNo reimbursement value

92531--spontaneous nystagmus92531--spontaneous nystagmus 92532--positional nystagmus92532--positional nystagmus 92533--caloric vestibular test92533--caloric vestibular test 92534--optokinetic nystagmus92534--optokinetic nystagmus

Audiological Assessment CodesAudiological Assessment Codes

92551--screening test, air only92551--screening test, air only92552--pure tone audiometry, air only92552--pure tone audiometry, air only92553--pure tone audiometry, air/bone92553--pure tone audiometry, air/bone92555--SRT92555--SRT92556--SRT and speech recognition92556--SRT and speech recognitionNo code for PI/PB (use modifier 22)No code for PI/PB (use modifier 22)

Audiological Assessment CodesAudiological Assessment Codes

92557--comprehensive audiometry92557--comprehensive audiometryBundled code (includes 92553 and 92556)Bundled code (includes 92553 and 92556)Do not code separately if all component Do not code separately if all component

tests are performedtests are performed92559--group audiometric test92559--group audiometric test

Middle-ear Function TestsMiddle-ear Function Tests

92567--acoustic immittance 92567--acoustic immittance (tympanometry)(tympanometry)

92568--acoustic reflexes92568--acoustic reflexes92569--acoustic reflex decay92569--acoustic reflex decay

Site of Lesion TestsSite of Lesion Tests

92571--filtered speech test92571--filtered speech test 92572--SSW92572--SSW 92576--SSI (ICM or CCM)92576--SSI (ICM or CCM) 92563--tone decay test92563--tone decay test 92564--SISI92564--SISI 92565--pure tone Stenger test92565--pure tone Stenger test 92577--speech Stenger test92577--speech Stenger test 92589--central auditory function test92589--central auditory function test

Less Commonly Used Less Commonly Used ProceduresProcedures

92573--Lombard test92573--Lombard test92575--SAL92575--SAL92562--loudness balance test (ABLB)92562--loudness balance test (ABLB)92560--Bekesy screening test92560--Bekesy screening test92561--Bekesy diagnostic test92561--Bekesy diagnostic test

Electrophysiological TestsElectrophysiological Tests

92584--electrocochleography92584--electrocochleography 92586--auditory evoked potentials, screening92586--auditory evoked potentials, screening 92585--auditory evoked potentials (ABR, MLR, 92585--auditory evoked potentials (ABR, MLR,

late potentials), diagnosticlate potentials), diagnostic 92587--otoacoustic emissions, screening92587--otoacoustic emissions, screening 92588--otoacoustic emissions, diagnostic92588--otoacoustic emissions, diagnostic 95920--intraoperative monitoring (added on to 95920--intraoperative monitoring (added on to

primary procedure, e.g. 92585)primary procedure, e.g. 92585)

Hearing Aid ServicesHearing Aid Services

92590--HAE, monaural92590--HAE, monaural 92591--HAE, binaural92591--HAE, binaural 92592--hearing aid check, monaural 92592--hearing aid check, monaural 92593--hearing aid check, binaural92593--hearing aid check, binaural V5014--hearing aid repairV5014--hearing aid repair 92594--electroacoustic test, monaural92594--electroacoustic test, monaural 92595--electroacoustic test, binaural92595--electroacoustic test, binaural


Programming--Use 92594 or 92595Programming--Use 92594 or 92595Ear impression--V5275 Ear impression--V5275 Real-ear measurement--V5020Real-ear measurement--V5020Otoscopy is part of examination and is not Otoscopy is part of examination and is not

coded separately. Video-otoscopy is coded separately. Video-otoscopy is diagnostic and is coded as 92700.diagnostic and is coded as 92700.


97703 (each 15 min)--hearing aid orientation97703 (each 15 min)--hearing aid orientation 92506--outcome measures92506--outcome measures 92507-aural rehabilitation (except implant)92507-aural rehabilitation (except implant) Considered to be part of fitting*:Considered to be part of fitting*:

device ordering/handling (99002)device ordering/handling (99002) special supplies (99070)special supplies (99070) patient education materials (99071)patient education materials (99071) group patient education (99078)group patient education (99078)

*not billable by audiologists*not billable by audiologists

Evaluation & ManagementEvaluation & Management

Level of care determined by Level of care determined by complexitycomplexityTime determines level only for counseling Time determines level only for counseling

and coordination of careand coordination of careOffice visits, inpatient services, consults, Office visits, inpatient services, consults,

case management, prevention, disability case management, prevention, disability assessment assessment

Evaluation & ManagementEvaluation & Management

Cannot be billed Medicare, Medi-gap, and Cannot be billed Medicare, Medi-gap, and many third-party payers but may be billed many third-party payers but may be billed to some HMOsto some HMOs

Controversy: use E&M? 99499? 99211?Controversy: use E&M? 99499? 99211? 99211 is allowed but does not describe level of 99211 is allowed but does not describe level of

service. 99499 is unspecified service and may service. 99499 is unspecified service and may not pass through billing system. Not not pass through billing system. Not appropriate when more specific codes are appropriate when more specific codes are applicable. applicable.

Balance TreatmentBalance Treatment

Audiologists treat vestibular disorders including Audiologists treat vestibular disorders including BPPV.BPPV.

Peripheral vestibular rehab (canalith repositioning) is Peripheral vestibular rehab (canalith repositioning) is within the audiologist’s scope of practice. Code within the audiologist’s scope of practice. Code 97112.97112.

PT/OT treats global balance problems (sensory PT/OT treats global balance problems (sensory integration, proprioception).integration, proprioception).

Dynamic posturography (92548) is within the PM&R Dynamic posturography (92548) is within the PM&R scope of practice.scope of practice.

Global vestibular rehabilitation (97112).Global vestibular rehabilitation (97112).

Audiology: HCPCS CodesAudiology: HCPCS Codes

V5008-hearing screeningV5008-hearing screeningV5010-V5298--hearing aid servicesV5010-V5298--hearing aid servicesV5299--miscellaneous hearing serviceV5299--miscellaneous hearing serviceL8614--cochlear implant device/systemL8614--cochlear implant device/systemL8619--speech processor replacementL8619--speech processor replacementL7510--repair of prosthetic device (not L7510--repair of prosthetic device (not

hearing aid)hearing aid)

CPT ModifiersCPT Modifiers


31 CPT modifiers31 CPT modifiers6 Anesthesia modifiers6 Anesthesia modifiers13 Ambulatory Surgery modifiers13 Ambulatory Surgery modifiers

Why Use Modifiers?Why Use Modifiers?

To indicate that a service was more or less complex To indicate that a service was more or less complex than typicalthan typical

To indicate that a service was repeated or To indicate that a service was repeated or discontinueddiscontinued

To add more information regarding the purpose or To add more information regarding the purpose or anatomic site of the procedureanatomic site of the procedure

To help to eliminate the appearance of duplicate To help to eliminate the appearance of duplicate billingbilling

To help to eliminate the appearance of unbundling To help to eliminate the appearance of unbundling (fragmentation).(fragmentation).


Not all modifiers are appropriate for use Not all modifiers are appropriate for use by audiologistsby audiologists

Modifiers should be used when Modifiers should be used when appropriate to describe or clarify the appropriate to describe or clarify the service provided.service provided.

Not all modifiers may be applicable to all Not all modifiers may be applicable to all codes.codes.


22--unusual procedural service22--unusual procedural service 26--professional component (interpretation)26--professional component (interpretation) 51--multiple procedures during same encounter51--multiple procedures during same encounter 52--reduced service. Example: unilateral 52--reduced service. Example: unilateral

procedure when bilateral is assumed.procedure when bilateral is assumed.


53--discontinued procedure53--discontinued procedure 59--distinct procedural service on same day59--distinct procedural service on same day 76--repeat procedure by same provider76--repeat procedure by same provider 77--repeat procedure by other provider77--repeat procedure by other provider 99--multiple modifiers99--multiple modifiers


The following modifiers are restricted:The following modifiers are restricted: 50--bilateral procedure50--bilateral procedure 76 and 77--not used for quality control or 76 and 77--not used for quality control or

verificationverification Other modifiers clearly identified as medical or Other modifiers clearly identified as medical or

surgical (21, 23, 24, 25, 27, 32, 47, 54, 55, 56, surgical (21, 23, 24, 25, 27, 32, 47, 54, 55, 56, 57, 58, 62, 66, 73, 74, 78, 79, 80, 81, 82, 90, 91)57, 58, 62, 66, 73, 74, 78, 79, 80, 81, 82, 90, 91)

Physical status modifiers (P1, P2, P3, P4, P5, Physical status modifiers (P1, P2, P3, P4, P5, P6)P6)

HCPCS ModifiersHCPCS Modifiers

TC--technical componentTC--technical componentCC--procedure code changeCC--procedure code changeRP--repair/replace prosthetic deviceRP--repair/replace prosthetic deviceRR--rental or lease of DME or prosthetic RR--rental or lease of DME or prosthetic

devicedevice

ICD-9 PCSICD-9 PCS

Used mainly for inpatient procedures Used mainly for inpatient procedures CPT used exclusively in U.S. for CPT used exclusively in U.S. for

outpatient procedure codingoutpatient procedure codingSurgical procedures (00.01-86.99)Surgical procedures (00.01-86.99)Diagnostic and therapeutic Diagnostic and therapeutic

procedures (87.01-99.9)procedures (87.01-99.9)Hearing tests (95.41-95.49)Hearing tests (95.41-95.49)

ICD-10-CMICD-10-CM

Replaces ICD-9-CMReplaces ICD-9-CMDisease and procedure sectionsDisease and procedure sectionsICD-10 PCS proposed as replacement ICD-10 PCS proposed as replacement

for CPTfor CPTAMA opposes ICD-10 PCS and is AMA opposes ICD-10 PCS and is

developing a new system, CPT-5developing a new system, CPT-5

Disease CodingDisease Coding

Structure of ICD-9-CMStructure of ICD-9-CM

3-, 4-, and 5-digit codes indicating levels of 3-, 4-, and 5-digit codes indicating levels of specificityspecificity

Updated annually by working groupUpdated annually by working groupDiseases and injuries (001-999)Diseases and injuries (001-999)Factors influencing health status and Factors influencing health status and

contact with health services (V-codes)contact with health services (V-codes)External causes of injury or poisoning (E-External causes of injury or poisoning (E-

codes)codes)

Principles of Disease CodingPrinciples of Disease Coding

General rule: code to the General rule: code to the highesthighest degree degree of of medicalmedical certaintycertainty..

Use the most specific code possible.Use the most specific code possible.Avoid NOS and NEC codesAvoid NOS and NEC codes..Non-physicians may code symptoms.Non-physicians may code symptoms.Choice of disease code has a great Choice of disease code has a great

affect on reimbursement.affect on reimbursement.

NEC and NOS CodesNEC and NOS Codes

NEC--NEC--not elsewhere classifiednot elsewhere classified (xxx.x8) (xxx.x8)NOS--NOS--not otherwise specifiednot otherwise specified (xxx.x9) (xxx.x9)NEC means that NEC means that no appropriate codeno appropriate code was was

found in the tabular list based on the found in the tabular list based on the information provided.information provided.

NOS means that the condition was NOS means that the condition was not not adequately describedadequately described by the provider. by the provider.

NOS codes are usually not acceptedNOS codes are usually not accepted

Inpatient Disease CodingInpatient Disease Coding

Principal diagnosis (DXLS)Principal diagnosis (DXLS)--condition --condition established established after studyafter study that occasioned that occasioned the admissionthe admission

V-codes are rarely used as V-codes are rarely used as principal principal diagnoses and rarely stand alone.diagnoses and rarely stand alone.

Exception: rehab servicesException: rehab services


““possible”, “probable”, “suspected”, or “rule possible”, “probable”, “suspected”, or “rule out” diagnoses are coded as out” diagnoses are coded as confirmedconfirmed..

““rule out”--diagnosis is possiblerule out”--diagnosis is possible““ruled out”--diagnosis is not possibleruled out”--diagnosis is not possibleIf condition is ruled out, it is If condition is ruled out, it is notnot coded. coded.Abnormal findings are Abnormal findings are notnot coded unless the coded unless the

clinic significance is indicated.clinic significance is indicated.


Conditions that have Conditions that have no bearing on current stayno bearing on current stay are not coded.are not coded.

All conditions All conditions observed during evaluationobserved during evaluation are are coded.coded.

Only conditions Only conditions treated or that have treated or that have directdirect bearing on the condition being treatedbearing on the condition being treated are are coded during treatment.coded during treatment.

Conditions that are Conditions that are integral to a diseaseintegral to a disease processprocess are not coded separately. are not coded separately.

Outpatient Disease CodingOutpatient Disease Coding

Condition that is Condition that is chieflychiefly responsibleresponsible for the for the patient’s visit is the patient’s visit is the primaryprimary diagnosis. diagnosis.

PrimaryPrimary diagnosisdiagnosis may be a disease, condition, may be a disease, condition, problem, symptom, injury, or reason for problem, symptom, injury, or reason for encounter.encounter.

SecondarySecondary diagnosesdiagnoses may describe co-existing may describe co-existing conditions, symptoms, or reasonsconditions, symptoms, or reasons

Do not code conditions previously treated Do not code conditions previously treated and and no longer exist.no longer exist.

Outpatient Disease CodingOutpatient Disease Coding

Do not code “probable”, “suspected”, Do not code “probable”, “suspected”, “questionable”, or “rule out” diagnoses. “questionable”, or “rule out” diagnoses.

Code to the highest degree medical certainty. Code to the highest degree medical certainty. If unsure, code If unsure, code symptoms or reasons.symptoms or reasons.

Symptoms may be coded as primary Symptoms may be coded as primary if a if a confirmed diagnosed has not been assignedconfirmed diagnosed has not been assigned..

As a general rule, follow outpatient rulesAs a general rule, follow outpatient rules

Primary and SecondaryPrimary and Secondary

PrimaryPrimary DiagnosisDiagnosis: disease, symptom, : disease, symptom, condition or reason that is chiefly condition or reason that is chiefly responsible for the visit.responsible for the visit.

SecondarySecondary DiagnosisDiagnosis: other diagnoses : other diagnoses (e.g. relevant chronic conditions), (e.g. relevant chronic conditions), conditions that have impact on care, or conditions that have impact on care, or other conditions found other conditions found after studyafter study..

Primary and SecondaryPrimary and Secondary

For treatment services:For treatment services: PrimaryPrimary DiagnosisDiagnosis: reason that is chiefly : reason that is chiefly

responsible for the visit.responsible for the visit. SecondarySecondary DiagnosisDiagnosis: Condition treated and : Condition treated and

other diagnoses (e.g. relevant chronic other diagnoses (e.g. relevant chronic conditions) or other conditions found conditions) or other conditions found after after study.study.

Routine or Administrative ExamsRoutine or Administrative Exams

PrimaryPrimary DiagnosisDiagnosis: appropriate V-code to : appropriate V-code to indicate the indicate the reason for the examreason for the exam

SecondarySecondary DiagnosisDiagnosis: any diagnoses, : any diagnoses, conditions, or symptoms found conditions, or symptoms found after studyafter study

Organization of V-codesOrganization of V-codes

Health hazards related to communicable diseases Health hazards related to communicable diseases (V01-V06)(V01-V06)

Health hazards related to personal or family history Health hazards related to personal or family history (V10-V19)(V10-V19)

Reproduction and development Reproduction and development (V20-V29)(V20-V29) Classification of live births Classification of live births (V30-V39)(V30-V39) Conditions influencing health status Conditions influencing health status (V40-V49)(V40-V49) Specific procedures and after-care Specific procedures and after-care (V50-V59)(V50-V59) Other circumstances Other circumstances (V60-V68)(V60-V68) Persons without diagnosis Persons without diagnosis (V70-82)(V70-82)

V-codesV-codes

Do not confuse ICD-9-CM V-codes with Do not confuse ICD-9-CM V-codes with HCPCS Level II V-codes.HCPCS Level II V-codes. ICD-9-CM codes are ICD-9-CM codes are diseasesdiseases, , conditionsconditions,,

symptomssymptoms, , oror reasonsreasons.. HCPCS Level II codes are HCPCS Level II codes are proceduresprocedures..

V-codesV-codes

Some V-codes must be coded as Some V-codes must be coded as primaryprimary; ; others are coded as others are coded as secondarysecondary

Consult your ICD-9-CM guide or your local Consult your ICD-9-CM guide or your local registered health information specialistregistered health information specialist

Audiology: ICD-9-CM V-codesAudiology: ICD-9-CM V-codes

V19.2 (family history of hearing loss)V19.2 (family history of hearing loss) V41.2 (problems with hearing)V41.2 (problems with hearing) V53.2 (fitting/adjustment of hearing aid)V53.2 (fitting/adjustment of hearing aid) V65.2 (non-organic condition)V65.2 (non-organic condition) V71.8 (observation for suspected condition)V71.8 (observation for suspected condition) V70.5 (disability exam)V70.5 (disability exam)

Normal FunctionNormal Function

There is no ICD-9-CM code for normal There is no ICD-9-CM code for normal function. Normal function is not coded as function. Normal function is not coded as a disease.a disease.

V65.5 when there are no risk factors. V65.5 when there are no risk factors. V71.89 when there is clinical reason to V71.89 when there is clinical reason to

suspect a problem.suspect a problem.

Coding and BillingCoding and Billing

CaveatsCaveats

Every insurance carrier has its own rules.Every insurance carrier has its own rules.Coding is not the same as billing.Coding is not the same as billing.Coding errors may lead to billing errorsCoding errors may lead to billing errorsEven accurate coding may lead to errors. Even accurate coding may lead to errors. Not all Not all billedbilled codes are codes are reimbursablereimbursable..Not all Not all encounterencounter codes are codes are appropriate or billableappropriate or billable..Billing errors, however innocent, may be viewed Billing errors, however innocent, may be viewed

insurance fraud.insurance fraud.

Coding RulesCoding Rules

Coding must conform to uniform coding Coding must conform to uniform coding standards.standards.

CMS has the right to audit medical records, CMS has the right to audit medical records, levy fines, and file claims for false and levy fines, and file claims for false and fraudulent billing.fraudulent billing.

Insurance carriers may also audit medical Insurance carriers may also audit medical records and file civil claims for fraud and records and file civil claims for fraud and abuse. May lead to civil and/or criminal abuse. May lead to civil and/or criminal penaltiespenalties

What is Required to Assure What is Required to Assure Accuracy (compliance)?Accuracy (compliance)?

Billing codes must match documentation.Billing codes must match documentation. Documentation must support the scope and Documentation must support the scope and

level of service (complexity or time).level of service (complexity or time). CPT codes must match diagnosis.CPT codes must match diagnosis. Services must be appropriate by provider type.Services must be appropriate by provider type. Services must be ordered by a physician (in Services must be ordered by a physician (in

writing)writing)

What will Medicare audit?What will Medicare audit?

Eligibility processes, identification and verification of Eligibility processes, identification and verification of insuranceinsurance

Medical record documentation, legibility, and accuracy of Medical record documentation, legibility, and accuracy of medical termsmedical terms

Medical record completenessMedical record completeness Consistency of descriptive and decision-making terms in the Consistency of descriptive and decision-making terms in the

medical recordmedical record Accuracy of encounter formsAccuracy of encounter forms Matching of medical terms in the record with encounter Matching of medical terms in the record with encounter

codescodes Accuracy of codes on claim form and bill sentAccuracy of codes on claim form and bill sent

Reasons for Fraudulent BillingReasons for Fraudulent Billing

Inadequate documentationInadequate documentationImproper codingImproper codingServices not providedServices not providedFragmentation (unbundling)Fragmentation (unbundling)Lack of medical necessityLack of medical necessity

Role of the ProviderRole of the Provider

Fully document clinical careFully document clinical careProvider is responsible documentationProvider is responsible documentationUse accurate encounter formsUse accurate encounter formsEncounter form is a tool. Documentation is Encounter form is a tool. Documentation is

what is important.what is important.Follow applicable coding and Follow applicable coding and

documentation guidelinesdocumentation guidelinesAssist in verifying claimsAssist in verifying claims

Coding Dilemma: Data Capture vs. BillingCoding Dilemma: Data Capture vs. Billing

Data captureData capture: enter codes that : enter codes that appropriately describe the service appropriately describe the service provided.provided.

PurposePurpose: workload reports, costing, : workload reports, costing, staffing, efficiency, health care trends, staffing, efficiency, health care trends, researchresearch


BillingBilling:: enter codes that is appropriately enter codes that is appropriately describe the service provideddescribe the service provided

PurposePurpose:: revenue generation revenue generation


ProblemsProblems: : Not allNot all codes entered for data capture codes entered for data capture purposes are appropriate for billing. purposes are appropriate for billing.

ExceptionsExceptions:: codes entered into non-billable clinics, codes entered into non-billable clinics, codes without chargescodes without charges

High probability of errors if data capture and billing High probability of errors if data capture and billing systems are linked.systems are linked.

ConcernsConcerns: : Codes may be eliminated if they are not Codes may be eliminated if they are not appropriate by provider type. Problematic codes appropriate by provider type. Problematic codes may be restricted or removed from encounter forms may be restricted or removed from encounter forms or software.or software.

LessonLesson

Provider must know the reason for Provider must know the reason for coding:coding: Data capture (workload, costing, etc.) Data capture (workload, costing, etc.) Reimbursement (revenue generation)Reimbursement (revenue generation)

Define the purpose of coding up Define the purpose of coding up front.front.

Coding rules are different for each Coding rules are different for each purpose.purpose.

What Can Be Done to Improve What Can Be Done to Improve Coding?Coding?

Coding handbooks and guidelinesCoding handbooks and guidelinesStandard encounter forms (super bills)Standard encounter forms (super bills)EducationEducationGood dialogue with coding and billing Good dialogue with coding and billing

officialsofficialsElectronic aids (templates, code filters, Electronic aids (templates, code filters,

prompts, taxonomies, e.g. CHCS-2)prompts, taxonomies, e.g. CHCS-2)

Provider BillingProvider Billing

ProvidersProviders may bill for services (e.g. may bill for services (e.g. physician services). physician services).

Non-providersNon-providers: Other types of : Other types of practitioners may provide services but practitioners may provide services but procedures are billed as procedures are billed as ancillaryancillary or or facilityfacility charges.charges.

Facility decides who is a provider. Facility decides who is a provider.

Billing by Non-providersBilling by Non-providers

Audiologists may bill for global (TC + 26 Audiologists may bill for global (TC + 26 components). components).

Audiologists may not bill Medicare for physician Audiologists may not bill Medicare for physician (E&M) services.(E&M) services.

Technical services may be billed as Technical services may be billed as facilityfacility charges charges ifif the procedure has technical (TC) the procedure has technical (TC) and professional (26) components.and professional (26) components.

Technical services are facility charges Technical services are facility charges regardless of who provides the serviceregardless of who provides the service..

Professional and Technical ServicesProfessional and Technical Services

Some CPT codes have both Some CPT codes have both technicaltechnical and and professionalprofessional components. components.

Technical component includes the time of the Technical component includes the time of the ancillary staff.ancillary staff.

Professional component includes the Professional component includes the physician’s work and expertise.physician’s work and expertise.

Technical services are billed as Technical services are billed as facilityfacility charges. charges. Professional services are billed as Professional services are billed as physicianphysician

services. services.

Medicare ChargesMedicare Charges

Hearing aid services are Hearing aid services are notnot covered covered services.services.

Routine services are not be covered.Routine services are not be covered.Treatment services by audiologists are not Treatment services by audiologists are not

covered.covered.All services must be ordered by a All services must be ordered by a

physician.physician.

Medicare ChargesMedicare Charges

Most procedures are billed as fMost procedures are billed as facilityacility charges. charges. ENG, ABR, and OAE have TC and 26 ENG, ABR, and OAE have TC and 26

components. components. Cerumen management is a Cerumen management is a physicianphysician charge. charge. Intraoperative monitoring has TC and 26 Intraoperative monitoring has TC and 26

components.components. Miscellaneous services (99000-99090) are Miscellaneous services (99000-99090) are

physicianphysician charges. charges.

Case Management ServicesCase Management Services

Case management services such as team Case management services such as team management (99361-99362) are physician management (99361-99362) are physician charges. charges.

These codes are considered as evaluation These codes are considered as evaluation & management codes which are not & management codes which are not appropriate for use by audiologists.appropriate for use by audiologists.

Advanced Billing IssuesAdvanced Billing Issues

Physician charges are billed on Physician charges are billed on HCFA HCFA 15001500..

Facility charges are billed on Facility charges are billed on UB-92UB-92..It is not appropriate to put a physician It is not appropriate to put a physician

charge on a UB-92 and then attach a TC charge on a UB-92 and then attach a TC modifier to indicate it is a “technical” (non-modifier to indicate it is a “technical” (non-physician) service.physician) service.

Medical NecessityMedical Necessity

Physicians determine Physicians determine medical necessitymedical necessity.. All orders, consultations, and referrals must be All orders, consultations, and referrals must be

signed and dated by physician.signed and dated by physician. All orders, consultations, and referrals must All orders, consultations, and referrals must

indicate indicate whywhy the care is medically necessary. the care is medically necessary. Referrals for evaluation must be medically Referrals for evaluation must be medically

necessary and pose a necessary and pose a diagnosticdiagnostic questionquestion..

Reasonable and NecessaryReasonable and Necessary

““reasonable and necessary for the reasonable and necessary for the diagnosis or treatment of an illness, injury, diagnosis or treatment of an illness, injury, or to improve the function of a malformed or to improve the function of a malformed body member.” body member.”

To be reimbursable, all services must be To be reimbursable, all services must be reasonable and necessaryreasonable and necessary..

Covered Audiology ServicesCovered Audiology Services

ordered by a physicianordered by a physician reasonable and necessaryreasonable and necessary used by the physician for evaluating appropriate used by the physician for evaluating appropriate

medical or surgical treatmentmedical or surgical treatment notnot coveredcovered when the diagnosis is when the diagnosis is known to the known to the

physicianphysician therapeutic servicestherapeutic services by audiologists are by audiologists are notnot

coveredcovered

DocumentationDocumentation

Principles of DocumentationPrinciples of Documentation

Documentation must be:Documentation must be: AccurateAccurate--describes the care provided--describes the care provided CodableCodable--supports CPT, ICD, DRG codes--supports CPT, ICD, DRG codes UnderstandableUnderstandable--clear to reader--clear to reader TimelyTimely--written at time patient was seen--written at time patient was seen Error freeError free--stands alone as a legal document--stands alone as a legal document


If ain’t documented, it weren’t done!If ain’t documented, it weren’t done!All care must be documented.All care must be documented.Anecdotal or historical events (patient not Anecdotal or historical events (patient not

present) should be documented.present) should be documented.All documentation must be dated and All documentation must be dated and

signed.signed.


Assessments must address:Assessments must address: chief complaint or reason for the visitchief complaint or reason for the visit pertinent medical, social, and family historypertinent medical, social, and family history examinations, diagnostic testsexaminations, diagnostic tests diagnosis or diagnostic impressionsdiagnosis or diagnostic impressions plan of careplan of care


Treatment plans are Treatment plans are derivedderived fromfrom assessments.assessments.

Treatment plans must address:Treatment plans must address: diagnoses, conditions, or problemsdiagnoses, conditions, or problems objectives or goals of treatmentobjectives or goals of treatment expected outcomesexpected outcomes treatment modalitiestreatment modalities duration of treatmentduration of treatment


To be reimbursable, To be reimbursable, allall treatment services must treatment services must be ordered by a physician.be ordered by a physician.

Ongoing treatments (e.g. AR) must be re-Ongoing treatments (e.g. AR) must be re-certified by the referring physician at least every certified by the referring physician at least every 30 days 30 days duringduring and at the and at the terminationtermination of of treatment.treatment.

All documentation must include:All documentation must include: patient’s name, SSNpatient’s name, SSN referring physicianreferring physician


Progress notes must address:Progress notes must address: goals or objectives of treatmentgoals or objectives of treatment progress toward stated treatment goals progress toward stated treatment goals documented, measurable outcomesdocumented, measurable outcomes alterations to treatment planalterations to treatment plan patient and/or family educationpatient and/or family education

Service Agreements Service Agreements and Referral Guidelinesand Referral Guidelines

Service AgreementsService Agreements

Bilateral agreement (contract)Bilateral agreement (contract)Usually between Audiology and Usually between Audiology and

Primary Care but can be with ENT or Primary Care but can be with ENT or any other referring source.any other referring source.

Service AgreementsService Agreements

Defines scope of services availableDefines scope of services availableReferral criteria (specific, pre-work)Referral criteria (specific, pre-work)Timeliness agreementsTimeliness agreementsRoles defined for both partiesRoles defined for both partiesCriteria for co-management or returnCriteria for co-management or returnCommunication methodsCommunication methodsMeasuring effectivenessMeasuring effectiveness

Referral GuidelinesReferral Guidelines

Operational version of service agreementOperational version of service agreementElectronic templateElectronic templateExamples: cerumen, sudden hearing loss, Examples: cerumen, sudden hearing loss,

routine repair/adjustment for hearing aid, routine repair/adjustment for hearing aid, disability or fitness exam, non-visit disability or fitness exam, non-visit consultconsult

Ensures appropriate, efficient, and timely Ensures appropriate, efficient, and timely referralsreferrals

Example: Sudden Hearing LossExample: Sudden Hearing Loss

Patient reports sudden hearing loss Patient reports sudden hearing loss in one or both ears. Time of onset in one or both ears. Time of onset and precipitating factors are and precipitating factors are important in diagnosis. Treatment important in diagnosis. Treatment must be started early to be effective.must be started early to be effective.

Send STAT consult to Audiology and Send STAT consult to Audiology and ENT followed by phone call to ENT followed by phone call to Audiology for appointmentAudiology for appointment

Consult TemplateConsult Template

Are ear canals clear of cerumen? Y/NAre ear canals clear of cerumen? Y/NDoes patient have associated Does patient have associated

dizziness? Y/Ndizziness? Y/NIs there evidence of middle-ear Is there evidence of middle-ear

effusuon or otitis with exudate? Y/Neffusuon or otitis with exudate? Y/NHearing loss in RE, LE, Both earsHearing loss in RE, LE, Both ears

Patient EducationPatient Education

What is Patient Education?What is Patient Education?

Preventive care & wellness programs?Preventive care & wellness programs? What about...What about...

advance directivesadvance directives informed consentinformed consent objectives, benefits, risks, alternatives to treatmentobjectives, benefits, risks, alternatives to treatment community resourcescommunity resources test results, health status, medical findingstest results, health status, medical findings treatment and discharge planstreatment and discharge plans patient and/or family responsibilitiespatient and/or family responsibilities

JCAHO RequirementsJCAHO Requirements

Required patient education:Required patient education: rehabilitative & compensatory techniquesrehabilitative & compensatory techniques safe and effective use of medical devicessafe and effective use of medical devices safe and effective use of medicationssafe and effective use of medications food/drug interactionsfood/drug interactions nutrition, modified diets, food consistencynutrition, modified diets, food consistency test results, health status, medical findingstest results, health status, medical findings treatment options and alternativestreatment options and alternatives

JCAHO RequirementsJCAHO Requirements

risks and benefits of treatmentrisks and benefits of treatment awareness of community resourcesawareness of community resources obtaining additional care, entitlements, obtaining additional care, entitlements,

access to care issuesaccess to care issues informed consent and advanced directivesinformed consent and advanced directives patient and family responsibilitiespatient and family responsibilities self care skills and personal hygieneself care skills and personal hygiene

Documentation of Patient EducationDocumentation of Patient Education

assess patients ability & readiness to learnassess patients ability & readiness to learn assess motivationassess motivation assess barriers and special needassess barriers and special need assess preferred mode of learningassess preferred mode of learning document educational content, mediumdocument educational content, medium document educational outcomes and level of document educational outcomes and level of

understandingunderstanding

Documents

Coding, Documentation, and Data Management Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs