Pittsburgh CME Conference November 7 - 9, 2014...Thomas Weida, MD, FAAFP, Penn State College of Medicine, Hershey, PA Disclosures: Speaker has no disclosures and there are no conflicts

Pennsylvania Academy of Family Physicians Foundation

Pittsburgh CME Conference

November 7 - 9, 2014

Billing and Coding Best Practices…Earn What You’re Worth Thomas Weida, MD, FAAFP, Penn State College of Medicine, Hershey, PA

Disclosures: Speaker has no disclosures and there are no conflicts of interest. The speaker has attested that their presentation will be free of all commercial bias toward a specific company and its products. The speaker indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices.

Capture the Coding, Outpatient

© Thomas Weida, M.D. 1

Thomas J. Weida, M.D.Professor, Penn State College of Medicine

© 2014, Thomas J. Weida, M.D. 2

Dr. Thomas Weida has no conflict of interest, financial agreement, or working affiliation with any group or organization.

1. Utilize proper documentation for CPT E&M coding

2. Apply proper CPT code use for common clinical situations, thereby avoiding under-coding or over-coding

3. Use medical decision making to guide E&M level




4

1. 992012. 992023. 992034. 992045. 992056. 992117. 992128. 992139. 9921410. 99215

5

1. 992112. 992123. 992134. 992145. 99215

6

1. 992112. 992123. 992134. 992145. 99215



None


Coding Captures What You Did, Not

Reimbursement

8

Element 99211 99212 99213 99214 99215

CC NA Required Required Required Required

HPI NA 1-3 1-3 4+ 4+

ROS N/A NA Pertinent 2-9 10

PFSH N/A N/A NA 1 of 3 1of each

Exam NA Focused Expanded Detailed Comp

Dx/Mgt NA Minimal Limited Multiple Extensive

Data NA Minimal Limited Moderate Extensive

Risk NA Minimal Low Moderate High

Hx

Px

Decision Making

locationqualityseveritydurationtimingcontextmodify fctassoc sx

2 of 3

One self limited problem

2 Minor self limited problemsOne stable chronic problemAcute simple illnessOTC Drug, PT, OT, Minor surgIV no additives

1 or > chronic problem withprogression or side effect

3 Stable Chronic IllnessesUndx new problem, uncertain pxAcute complicated injury Prescription drug

1 or > chronic with severe exacerbation

Threat to life or function

Abrupt neuro change

Parenteral controlled sub.

Major surgeryRx with intensivemonitoring

PennState Hershey Medical Center

2 of 3


New: A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Established: A patient who has been seen within the past three years.

New > Three Years



10

Element 99201 99202 99203 99204 99205

CC Required Required Required Required Required

HPI 1-3 1-3 4+ 4+ 4+

ROS N/A Pertinent 2-9 10 10

PFSH N/A N/A 1 of 3 1 of each 1of each

Exam Focused Expanded Detailed Comp Comp

Dx/Mgt Minimal Minimal Limited Multiple Extensive

Data Minimal Minimal Limited Moderate Extensive

Risk Minimal Minimal Low Moderate High

Hx

Px

Decision Making

locationqualityseveritydurationtimingcontextmodify fctassoc sx

2 of 3


2 Minor self limited problemsOne stable chronic problemAcute simple illnessOTC Drug, PT, OT, Minor surgIV no additives

1 or > chronic problem withprogression or side effect

2 Stable Chronic IllnessesUndx new problem, uncertain pxAcute complicated injury Prescription drug

1 or > chronic with severe exacerbation

Threat to life or function

Abrupt neuro change

Parenteral controlled sub.

Major surgeryRx with intensivemonitoring

PennState Hershey Medical Center

3 of 3

Overall MDM Problem Points

Data Points Level of Risk

Straightforward Complexity (992x2)

1 1 Minimal

Low Complexity(992x3)

2 2 Low

Moderate Complexity(992x4)

3 3 Moderate

High Complexity(992x5)

4 4 High


Need Two of Three to Qualify for Level


Problem Points

Self limited or minor (maximum of 2) 1 eachEstablished problem, stable or improving 1 eachEstablished problem, worsening 2 eachNew problem, no additional work up planned (maximum of 1) 3New problem, with additional work up planned 4



Data Reviewed PointsReview or order clinical laboratory tests 1Review or order radiology tests (except echo or heart cath) 1Review or order medicine test (PFT, EKG, Cardiac Cath, Echo, etc. *) 1Discuss test with performing physician 1Independent review of tracing, image or specimen (i.e. EKG, KOH, UA)

2

Decision to obtain old records 1Review and summation of old records 2

13

* EKGs, EEGs, PFTs, echocardiograms, cardiac catheterizations, cardiac stress tests, audiometry, speech or swallow studies, pacemaker interrogations, arterial or venous doppler studies, plethysmography, non-invasive arterial studies (such as ABIs), transcranial doppler studies, allergy testing, sleep studies, EMGs, evoked potentials, tensilon testing and nutritional assessments

Risk Presenting Problems

Diagnostic Options Management Options

Minimal (992x2)

Minimal Routine Labs, EKG, X-rays, USN, Echo, EEG

Advice

Low (992x3)

Low PFT, Contrast X-rays, ABG, Skin Biopsy

OTC, PT, OT, Minor Surgery, IV – no additives

Moderate (992x4)

Medium Stress tests, endoscopies, Cardiac cath, LP, Thoracentesis

Prescription Drugs, IV’s with additives, Major surgery – no risk factors, Minor surgery with risk, Closed fracture, Nuclear med treatment

High (992x5)

High Cardiovasc imaging with risk factors, EP studies, Endoscopy with risk, Discography

Surgery with risk, Emergency surgery, Narcotics, Drug therapy with extensive monitoring, DNR decision


15

1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment

Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)

Abrupt neuro status change (TIA, Sx, weakness, sensory loss)

4 HPI elements 10 ROS 1 of each PFSH

Comprehensive (general multisystem or complete single organ)

Decision Making History

Physical

40 min



16

3 chronic stable illnesses 2+ or more chronic stable

illnesses 1+ chronic illness with

exacerbation Undiagnosed new problem

with uncertain diagnosis Acute illness with systemic

symptoms Acute complicated injury

4 HPI elements 2-9 ROS 1 of 3 PFSH

Detailed (affected area and related organ system)


Physical

25 min

17

2 or more self limited problems

1 stable chronic illness acute uncomplicated illness

(cystitis, sprain)

1-3 HPI elements

Pertinent ROS

Expanded problem focused


Physical

15 min

18

1 or more chronic illness with severe exacerbation, progression or side effects of treatment

Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress)

Abrupt neuro status change (TIA, Sx, weakness, sensory loss)


Comprehensive (general multisystem or complete single organ)


Physical

60 min



19

3 chronic stable illnesses 2+ or more chronic stable

illnesses 1+ chronic illness with

exacerbation Undiagnosed new problem

with uncertain diagnosis Acute illness with systemic

symptoms Acute complicated injury


Comprehensive(general multisystem or complete single organ)


Physical

Looks like a 99215

45 min

20

2 or more self limited problems

1 stable chronic illness acute uncomplicated illness

(cystitis, sprain)

4 HPI elements 2-9 ROS 1 of 3 PFSH

Detailed (affected area and related organ system)


Physical

Looks like a 99214

30 min


Data Points Level of Risk


1 1 Minimal


2 2 Low


3 3 Moderate


4 4 High

21

Need Two of Three to Qualify for Level

Established problem, stable or improving – 1 ptEstablished problem, worsening – 2 pt eachNew problem, no additional work up planned (maximum of 1) 3 pt

Prescription Drugs



22

20 min

10 min


Focused exam 1-3 HPI elements


Expanded problem focused exam

1-3 HPI elements Pertinent ROS

Looks like a 99213

23

BP check by nurse Weight check for CHF Lab draw Picking up prescription refill Picking up return to work or school

certificate. (If mail or call in, no CPT code allowed)

May not require physician presence

5 min

“Coding from the Bottom Up,” Thomas Weida, David O’Gurek, Family Practice Management, November 2008

24

The specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances.

Face-to-face for office and outpatient

Unit/floor for hospital and inpatient

Time is not a criteria for level of service.

99205 – 60 min99204 – 45 min99203 – 30 min

99215 – 40 min99214 – 25 min99213 – 15 min



25

Counseling: a discussion with a patient and/or family concerning: Diagnostic results, or recommended studies Prognosis Risks & benefits of treatment Importance of compliance Risk factor reduction Patient and family education

Not just psychological counseling If counseling > 50% of visit time, can use

counseling documentation for level.

Examples - Outpatient

26

1. 992112. 992123. 992134. 992145. 99215

What else is needed?

4 HPI

2-9 ROS or

1 of PFSH

Detailed physical (affected and related organ system)

27

What else is needed?1. 992112. 992123. 992134. 992145. 99215

•1-3 HPI elements

•Pertinent ROS or

•Expanded problem focused physical



28

1. 992112. 992123. 992134. 992145. 99215

29

1. 992112. 992123. 992134. 992145. 99215

30

1. 992112. 992123. 992134. 992145. 99215



31


Data Points

Level of Risk


1 1 Minimal


2 2 Low


3 3 Moderate


4 4 High

32

Problem Points

Self limited or minor (maximum of 2) 1 each

Established problem, stable or improving 1 each

Established problem, worsening 2 each

New problem, no additional work up planned (maximum of 1) 3

New problem, with additional work up planned 4

33

1. 992112. 992123. 992134. 992145. 99215



34

1. 992012. 992023. 992034. 992045. 99205

Medical decision making of 99214 History and physical of 99215

35

1. 992112. 992123. 992134. 992145. 99215

36

1. 992012. 992023. 992034. 992045. 99205



37

1. 992112. 992123. 992134. 992145. 99215

38

Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

Best to have two different diagnoses E&M -25 and procedure code Example: laceration which you evaluate

and then repair with sutures Document two independent notes

CPT 2000, pg. 403-404


3 chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain

diagnosis Acute illness with systemic symptoms Acute complicated injury



40

1. 992012. 992023. 992034. 992045. 992056. 992117. 992128. 992139. 9921410. 99215

41

1. 992112. 992123. 992134. 992145. 99215

42

1. 992112. 992123. 992134. 992145. 99215



43

1. 02. 13. 24. 35. 46. 5 – 77. > 8

Medicare Rates


Undercoded/day 1 2 3 4 5 8

Non facility $

8,331.60 $

16,663.20 $

24,994.80 $

33,326.40 $

41,658.00 $

66,652.80

Facility$

6,903.60 $

13,807.20 $

20,710.80 $

27,614.40 $

34,518.00 $

55,228.80

Pull 10 notes and check coding against easy to use guidelines.

Mentally calculate how much revenue lost Kick self Repeat process till no longer kicking self Simple


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Documents

Pittsburgh CME Conference November 7 - 9, 2014...Thomas Weida, MD, FAAFP, Penn State College of Medicine, Hershey, PA Disclosures: Speaker has no disclosures and there are no conflicts