NCSCHA Breaking the Code Workshop

8/13/2019 NCSCHA Breaking the Code Workshop

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1

NCSCHA 2010 A CP: L B, N A SB H C (NASBHC)

C S, NC D P H, C & B

K L, NP, NCSCHA B M

Children and Youth Branch


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O D, ,

ICD9 CP C

.

D

.

2

S 4 7 S

H C .

D ICD9 CP E

M C CE.

D

.


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C B C B

3


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C C

4

Current Procedural Terminology (CPT)

International Classification of Diseases(ICD-9 Clinical Modification - CM)

Diagnostic and Statistical Manual of Mental

Disorders (DSM IV-TR)


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C NC N

Procedure codes indicate what wasdone. (e.g. CPT; HCPCS)

5

Diagnosis codes justify why it wasdone. (e.g. ICD-9-CM)


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OO

CPT and ICD-9 codes must alwaysrelate

6

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


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H C C H C C

There is no difference between codingin a SHC and any other setting the

7

. You provide the same level of care

regardless of the location.


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? ?

Tell your story

Documentation

Reimbursement

8

e ca a tyRisk of Medicaid Review/Audit

Provider Profiling

Patient Labeling

Epidemiological Tracking

Internal Tracking


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The wrong story is:

SHC providers are seeing very few patients withm l i l r l m .

9

SHC providers should see more patients since theyare not seeing complicated patients.

The SHC should decrease the number ofphysicians and add more mid-level providers.


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FF

Intentionaldeception ormisrepresentation

10

Deliberately billing for services notperformed

Unbundling of services

Intentionally submitting duplicate claims


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AA

Improper billing practices

-

11

Misusing codes on a claim form


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EE

Accept it; you will make them.

Your best defense is having alan for our codin and

12

being able to explain it.


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Coding Does NotCoding Does NotEqual GoodEqual Good

MedicineMedicine

13


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BB C RC RG D G D

J C J C

14


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G C PG C P

Coding gets you paid for your services

15

Coding can be used to justify the need forservices to your funders


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ICDICD99CM D CCM D C

16


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ICDICD99CM CCM C

Used by all insurers

Codes are made upof 3, 4, or 5 digits

Source documents

should support thediagnosis code(s)selected

17

numer c oralphanumeric)

Codes are updated

annually

Failure to codeproperly can result infines, sanctions ordecreased revenue


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ICDICD99CM C BCM C B

Volume 1: Disease Tabular IndexNotes all exclusive terms and 5th-digit instructions

18

Does not contain detail; do not code from this volume

Volume 3: ICD-9-CM Procedure Codes

Only used by hospitals to report inpatient procedures


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ICDICD99CM CCM CRange from 001.0 to V89.09

They identify:

Diagnoses

19

SymptomsConditions

Problems

Complaints

Other reason for the procedure, service,

or supply provided


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ICDICD99CM C ECM C E

Streptococcal Pharyngitis 034.0

Tobacco Abuse 305.1

Acute Bacterial Pneumonia 482.9

20

Dysmenorrhea 625.3

Asthma 493.90

Dermatitis due to sunburn 692.71

Obesity 278.00


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Generalized Abd. Pain789.07

Heart Murmur 785.2

21

Nausea & Vomiting 787.01

Positive TB Skin Test 795.5

Headache 784.0


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CCUsed when patient is not currently sick

To classify factors influencing health status.

(e.g. Pregnancy; Family/Personal Health History)

22

To classify type of contact with health services.

(e.g. Well Child Check-up; Sports Physical)

Alphanumeric Code

V-Codes can be problem-oriented, service orientedor factual


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C C

Can be used as a:

23

Solo Code

Principal Code

Secondary Code


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C !C !

When locating a V-Code in the Alphabetic Index,

use the reason for the visit as the main term.Common terms in alphabetic index where V-codesare found include:

24

Aftercare

Checking

CheckupExamination

Follow-up

History (of)

Observation (for)

Problem (with)Screening (for)

Vaccination


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CC

V-Codes are used for:

Routine examinations

25

Follow-up examinations

Pre-op examinations

CounselingScreening


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MMR Vaccination V06.4

Well Child Checku V20.2

26

Sports Physical Exam V70.3

Suspected Pregnancy V72.40


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ICDICD99CM CCM C

E Codes

(External Causes of Injury or Poisoning)

Always a 2ndary diagnosis.

27

Optional Codes-Use with caution.

How an accident occurred

What caused an injury

Whether a drug overdose was accidental

An adverse drug reaction

Location of occurrence


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C !C !

Whenever possible, avoid ICD-9-CM

Codes that are labeled:

-

28

NOS - not otherwise specified

Always code to the highest level ofspecificity (5th digit) if possible.


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C !C !Do not code diagnoses documented as

probable, suspected or rule out as ifthe diagnosis is established.

29

In these instances code the symptoms, signs,abnormal test results or other reason for the visit.

If no condition or problem is documented at the end

of the visit, code the documented chief complaint orsymptom.


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C !C !

First diagnosis code should describethe chief reason for the service.

30

Link procedures with justifyingdiagnosis.


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C O PC O P

H H


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O O

B D B D

NO

P M S C

S/C C

32

I C

N C

S C

P/R C O C (HCPCS; S C)

S / L C


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N P . E PN P . E P

A

,

33

, .

A

, , .


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D M ND M N S

.

34

A .

.


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NNO O

CP 99211 O

, . , ()

35

.

L241 N RN (). S HD SHC DPH.

C .


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B P RB P R

RR

.

O (.. B F/GAPS/

36

.

S

C.

C C C C.


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B P RB P R

RR

S

C .

S (CP 99211)

37

. N: B M

, .

E

.


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B P RB P RRR

.

A RN/LPN

38

.

D CMA/LPN , RN / NP/PA.

D .


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Do we have

triage form

for concern?

Must meet all 3 criteria:

1. Less than 15 minutes

2. Triage form used with

minimal additional data

collection

3. Self limiting condition

Must meet at leasttwo criteria:

1. More than 15 minutes

2. Additional data documented on

triage form

3. Requires consultation

4. Additional procedures performed

Student comes in for a

acute care walk-in visit

Secretary gives triage

form to student to

complete first section

Secretary puts t riage form,

service slip and chart in

nurses door

Nurse completes triage visitBillable?

Yes

No

Complete

per standing

Is it a nurse

visit?

Yes

No

Nursing Billable Visits Flow

39

Code as a 99211

with the ICD-9 that

addresses the

symptomsassociated with the

visit

Not billable

Use nonbillable visit

procedure code to

document (LU241)

Keep documentation

limited to triage form

only.

Billable

Contact the parent

by telephone to

discuss billable visit

and document

minor, do

not bill

Schedule with

NP

If initial visit for

student, must refer

to NP. Nurse

cannot bill 99211 for

new patients.


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P M CP M C

(CP 99381(CP 9938199397)99397)C & . .

I , ,/ / ,

/ .

40

I ( & ),

. S

. N: S #1113

.

E/M .

I

, L208.


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P M CP CP M CP C ICD ICD9 D C 20.2 R 9 D C 20.2 R

A N E

41

14 99382 99392

511 99383 99393

1217 99384 99394

1839 99385 99395


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A P A P

C PC P When doing a preventive health visit (V20.2) and there is a separate acute

health problem you can list both the preventive health visit code (first) and

the acute visit code (second).

The provider must list ICD-9 codes that justify both.

42

The billing department must add a modifier (-25) ,

For NC Medicaid, the policy is as follows:

. . ,

()

.


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/ C C / C C

(P M A O C)(P M A O C)

CP 92551 H

CP 99173 S , ,

L D, SD, P; P S; P; .

43

Q B/M H P; ( ) ICD9CM C (.. D; A; .)

CP 9940699407 S & C C

CP 9940899409 A &/ S ( )

S S B ICP 99420 A. & I H R A

I:

H R A: B F, GAPS, HEADSSS, M

EB M H S (.. PSC, SDQ, PHQ9, BDIPC)


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I CI CI A C

F I:

CP 90471 (I )

44

CP 90472 (E A )

F I O

CP 90473 (I ) CP 90474 (E A )

C (CP 90476 90749)

A CA C


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A CA C

CP CCP C ICDICD9 C9 C

H A 90633 05.3

H AH B 90636 05.3

H P 90649 04.89

I, S , P F 90656 04.81

I, S 90658 04.81

45

, , .

M, M & R MMR* 90707* 06.4

P, I IP* 90713* 04.0

& D 90714 06.5

, D & A P * 90715* 06.1

* 90716* 05.4P P, 23 PP23 90732 03.82

M, S A,C,,135 ()MC4 90734 03.89

H B* 90744* 05.3

* Vaccines required by NC law for school entry.


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N CN CM N C

CP 97802 I A & I, 15 CP 97803 RA I, 15

CP 97804 G MN (2 ), 30

46

NB N C

L239

DPH .


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C CP 10021 C CP 100216997969979M HC:

CP 10060 I D A, S CP 10061 I D A, M

CP 11975 I, I C C

47

CP 11981 I, NB D D I CP 11982 R, NB D D I

CP 17000 D L , S

CP 17003 D L , 2+

CP 29130 A F S CP 36415 C B

CP 69210 R I C

P / RP / R


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P / RP / R

(CP 94010(CP 9401094799)94799)

I ,

,

48

. A 25 E/M .

O ,

. CP 99211.


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O CO CHCPC

A C M S S J C D A O O M

49

C C

.

HCPCS (A C) CP 99070 D .


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L C L CC

.

50

L208 L S P (R O)

L237 NB S C (R O)

L238 NB H E C (R O)

L239 NB N C (R O) L241 N B RN C (R O)


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L CL C

C

, .

51

I

. C

. , CP HCPCS C.


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O C O C

H C H C

CM C GCM C G


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CM C GCM C G

1995 .19971995 .1997

Both 1995 and 1997 guidelines are approved for

use by CMS.

Agencies should specify use of 1995 or 1997

53

u v .

This lecture is based on the 1995 guidelinesbecause they are 15 pages long vs. 57 pages of

the 1997 version.

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

E & ME & M


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E & ME & M

(O ) C(O ) C

E/M (E/M)

.

N P . E P

54

N P (CP 9920199205): , , .

E P (CP 9921199215): , , .

B F


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B F

A O C

C

55

, .

K C K C


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K C K C

L E/M L E/M H (S F)

E (O F)

M D M (A & P)

56

( 9920199205) . ( 9921299215)

. .

50% / , / . 2324.

E/M (O )


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E/M (O )

5 . CP . 5 .

& P F (PF); E PF(EPF); D (D) C (C).

S (SF); L C(LC); M C (MC) H C (HC).

. .

57

N P E P

N/A L 1: 99211 M

L 1: 99201 PF; PF; SF L 2: 99212 PF; PF; SF

L 2: 99202 EPF; EPF; SF L 3: 99213 EPF; EPF; LC

L 3: 99203 D; D; LC L 4: 99214 D; D; MC

L 4: 99204 C; C; MC L 5: 99215 C; C; HC

L 5: 99205 C; C; HC N/A

C O L


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N P

H PF EPF D C C

E PF EPF D C C

* Requires 3 components in one column be met or exceededto select that CPT code level.

C MDM SF SF L M H

A

(M)

10 20 30 45 60

L 1

CP

99201

2

CP

99202

3

CP

99203

4

CP

99204

5

CP

99205

C O L


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E P

H M

PF EPF D C

E PF EPF D C


.C MDM

SF L M H

A

(M)

5 10 15 25 40

L 1

CP

99211

2

CP

99212

3

CP

99213

4

CP

99214

5

CP

99215

CP 99211 M


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CP 99211 M

E P

CP 99211 O

, . () . 5

.

60

S . (.. RN

CP 99211

S H C ).

I ,

. (, )

/ .

K E H C


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K E H C

C C (CC)

M EER

H P I (HPI)

61

/

R (RO)A /

P, F, / H (PFH)A /

H P I (HPI)


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H P I (HPI)

L:

?

:

?

Q:

C:

HPI .*

62* Each element counts as one. Maximum score 8.

?

?:

H ? P

.

M F:

?

D:H

?

A / :A

?


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R (RO) A /

.

*

S ()

G G

M

63

C

E

E, N,

C

R

N H/L

E

P

A/I

* Each system counts as one. Maximum score is 14.

P, F, / H*


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, , /

(PFH)

P M/ H:A / /; ; (,,); .

64

A .

H:A / ( ,/ , /,// , , , )

* Each type of history counts as one. Maximum score is 3.


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H C (N HPI, ROS & PFSH *)

PROBLEM-

FOCUSED

EXPANDED

PROBLEM-FOCUS

DETAIL COMPREHENSIVE

CC Required Required Required Required

65

HPI Brief(1-3 elements)

Brief

(1-3 elements)

Extended

(>4 elements)

Extended

(>4 elements)

ROS None Pertinent toProblem

(1 system)

Extended

(2-9 systems)

Complete

(> 10 systems)Can count all others

negative.

PFSH None None Pertinent(New=2 hx areas)(Est. = 1 hx area)

Complete(New = 3 hx areas)

(Est. = 2 hx areas)

* Overall history level is determined by the column marked furthest to the left.

K E E C


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I 7

14 ( 1995 G

MS E G)*:

Body Areas:

Head/faceChest/breasts/axillaeAbdomen

Back/spine

66

Organ Systems:

Constitutional(Vital Signs; Wgt Loss; Gen Appearance)

Eyes

Ears/Nose/Mouth/ThroatCardiovascularRespiratoryGastrointestinalGenitourinary

MusculoskeletalIntegumentary (Skin)NeurologicalPsychiatricHematologic/LymphaticEndocrineAllergic/Immunologic

* Each body area / organ system counts as one.

ec Genitalia/groin/buttocks


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E C

PROBLEM-FOCUSED

EXPANDEDPROBLEM-

FOCUSED

DETAILED COMPREHENSIVE

67

Examination1 body area /organ system

2-7 body areas/organ systems

2-7 body areas/organ systems

8 or more body areas/organ systems

K E M D


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M C

/ .

C

:

68

A. N /

.

B. R , /

()

C. A/ , , /

, , .

D & / .

M .

M DM


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A. N D O

P E P N

P = R

S/ (, , ) 1 M=2

E. ( ); , 1

69

E. ( ); 2

N ( ); . 3 M=3

N ( ); . 4

B A N D/ O

F M D M (PP 75).

OAL

M D M


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B. R C +/ M MF PP : , , , .

M

PresentingProblem(s) DiagnosticProcedure(s)Ordered

ManagementOptions Selected

70

I

N

I

M

A

L

One self-limited orminor problem, e.g.cold, insect bite, tineacorporis.

Laboratory testsrequiring venipuncture

Chest x-rays

EKG/EEG

Urinalysis

Ultrasound, e.g. echo

KOH prep

Rest

Gargles

Elastic bandages

Superficial dressings

M D M


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B. R C +/ M M

L

PresentingProblem(s)

DiagnosticProcedure(s)

Ordered


Two or more self-

limited or minor

Physiologic tests not

under stress, e.g.

Over the counter drugs

71

O

W

pro ems

One stable chronicillness, e.g. well

controlled

hypertension, non-

insulin dependent

diabetes, cataract,

benign prostatic

hyperplasiaAcute uncomplicated

illness or injury, e.g.

cystitis, allergic

rhinitis, simple sprain

pu monary unc on es s

Non-cardiovascularimaging studies with

contrast, e.g. barium

enema

Superficial needle biopsies

Clinical laboratory tests

requiring arterial puncture

Skin biopsies

identified risk factors

Physical therapy

Occupational therapy

IV fluids without additives

M D M


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B. R C +/ M M

MO



Ordered


One or more chronicillnesses with mild

exacerbation, progress,

or side effects of

treatment

Physiologic tests under

stress, e.g. cardiac stress

test fetal contraction stress

Minor surgery with


72

ER

A

TE

Two or more stable

chronic illnessesUndiagnosed newproblem with uncertain

prognosis, e.g. lump in

breast

Acute illness with

systemic symptoms,e.g. pyelonephritis,

pneumonitis, colitis

Acute complicated

injury, e.g. head injury

with brief loss of

consciousness

test

Diagnostic endoscopieswith no identified risk

factors

Deep needle or incisional

biopsy

Elective major surgery

(open, percutaneous or

endoscopic) with noidentified risk factors

Prescription drug

management

IV fluids with additives

Closed treatment offracture or dislocation

without manipulation

M D M


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B. R C +/ M M

H



Ordered


One or more chronicillnesses with severe

exacerbation,

progression, or side

effects of tx

Cardiovascular imagingstudies with contrast with


Elective major surgery(open, percutaneous or

endoscopic) with identified

risk factors

73

GH

Acute or chronic

illnesses or injuriesthat may pose a threat

to life or bodily

function

(e.g. multiple trauma, acute MI,pulmonary embolus, severe

respiratory distress, progressive

severe rheumatoid arthritis,psychiatric illness with potentialthreat to self or others, peritonitis,

acute renal failure, sent to ER,eminent delivery)

Diagnostic endoscopies

with identified risk factors

Discography

Emergency major surgery

Parenteral controlled

substances

Drug therapy requiring

intensive monitoring fortoxicity

Final score is the highest component marked.Bring the Risk Level from B - Risk of Complications +/or Morbidity or Mortality

into final scoring for Medical Decision Making (see PPT slide 75).

M DM


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C. A +/ C D RD R P

R +/ 1R +/ CP 1

R +/ CP 1

74

D 1

D +/

1

R + +/

+/ 2

I , (

)2

B C A +/ C D R

F M D M ( PP 75). OAL

M D M


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M D M

L D M

L

C

M

C

H

C

A: N

M(4)

+

75

M M

C: A +/ C

D

M

L

(4)

*To score medical decision making, two of the three elementsin the table above must be met or exceeded.


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O F C /C/C C

CP , / ( 50%) / / (

76

E/M .

C : ,/ , ,

/ , ,, .

E & M

> 50%


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E/C

O NE

C 99201 99202 99203 99204 99205

() 10 20 30 45 60

77

D :

>50%

/ (..: )

C 99211 99212 99213 99214 99215 () 5 10 15 25 40

C O L


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N P

H PF EPF D C C

E PF EPF D C C


C M

DM

SF SF L M H

A

(M)

10 20 30 45 60

L 1

CP

99201

2

CP

99202

3

CP

99203

4

CP

99204

5

CP

99205

C O L


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E P

H M

PF EPF D C

E PF EPF D C


.C M

DM

SF L M H

A

(M)

5 10 15 25 40

L 1

CP

99211

2

CP

99212

3

CP

99213

4

CP

99214

5

CP

99215


80/85

C E

80

C


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E/M (9905099058).

C C (9929199292)

81

.

P C(9935499359)

E/M E/M C

C C


82/85

L

82

A ..

).

DD


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I , .

.

:

D

R

83

P /

A , A

S

SOAP

D E/M .

.

D ()D ()


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H .

, / , .

D

84

.

I , ; / ; .

CP ICD9CM .


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Q?

85

Documents

NCSCHA Breaking the Code Workshop