POH/DMC UROLOGYPOH/DMC UROLOGYGrand Round ConferenceGrand Round Conference

POH/DMC UROLOGYPOH/DMC UROLOGYGrand Round ConferenceGrand Round Conference

Presented by: Spectrum Billing Technologies, LLCPresented by: Spectrum Billing Technologies, LLC

Coding & ComplianceCoding & Compliance

Teaching Hospital• A hospital engaged in an approved

Graduate Medical Education (GME) residency program in Medicine, Osteopathy, Dentistry, or Podiatry

Teaching Physician• Teaching physician is a physician

(other than a resident) who involves residents in the care of his or her patients

Payment• Payments under the physician fee

schedule are made if the services are furnished by a physician, jointly by a physician & resident, or by a resident in the presence of a teaching physician

E&M Payment Under the Physician Fee

Schedule• A personal notation must be made by

the teaching physician demonstrating his/her presence in the history, exam, and medical decision making with a brief, summary comment related to the resident’s entry to confirm or revise key elements

Surgical Procedure Payment Under the

Physician Fee Schedule• In the case of a surgical procedure,

the teaching physician must be present during all critical portions of the procedure and must be immediately available to furnish services during the entire procedure

Minor Procedure Payment Under the

Physician Fee Schedule

• The teaching physician must be PRESENT for the entire procedure

“Billing Codes”

• CPT CODE

Describes WHAT was done

• ICD9 CODE

Describes WHY it was done

CPT Code Defined

• CPT codes describe medical procedures and services

• All CPT codes are 5 digit codes• Each CPT code represents the

universal definition of a service or procedure

CPT, Continued

• CPT coding controls the health care provider’s reimbursement

• Accurate CPT coding provides effective communication of medical services among healthcare entities

CPT/ICD9 Relationship• The ICD9 code must provide an

indication of MEDICAL NECESSITY for the service (CPT code) provided

• Insurance companies “link” each type of service with specific diagnosis codes that support the “reason” for the service

Evaluation & Management

• Outpatient E&M services require a differentiation for new vs established patients

• Code selection will affect the provider’s reimbursement….new patient codes are paid a higher rate

New vs Established Patient

• A new patient is one who has not received any professional services from the physician (or specialty group) within the past 3 years

• An established patient is one who has received professional services from the physician (or group) within the past 3 years

New Patient Coding

• New patient outpatient Evaluation & Management codes are 99201, 99202, 99203, 99204, and 99205

• The “level” of service is determined by 3 Key Components of the visit…History, Exam, Medical Decision Making

Established Patient Coding

• Established patient Outpatient E& M Codes are 99211 (Nurse Visit), 99212, 99213, 99214, and 99215

• The “level” of service is determined by 3 Key Components of the visit…History, Exam, Medical Decision Making

Chief Complaint• A concise statement describing

the symptom, problem, conditions, diagnosis or other factor that is the reason for the encounter, usually stated in the patients words…..

Past Family Social History

• A review of medical events in the patient’s family that includes information about parent, sibling, children health history

• Specific diseases related to problems identified in the chief complaint

PFSH, cont.• Diseases of family members which

may be hereditary or place the patient at risk

• Patient history, surgery, obstetrics, illness, injury, immunization, etc.

• Tobacco, alcohol, drugs, violence, diet

History of Present Illness

A chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present (location, quality, severity, timing, context, modifying factors and associated signs and symptoms).

Review of SystemsAn inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing, or has experienced….i.e. weight gain, abnormal bleeding, masses, etc.

Examination• General multi-system exam or a

single organ system exam may be performed by any physician regardless of specialty

• The content of the exam is selected based on clinical judgement, patient history, and the nature of the presenting problem

Medical Decision Making

• Diagnosis AND/OR management options

• Amount/Complexity Data• Risk of Complications

Counseling – Coordination of CareWhen counseling/coordination of care dominates more than 50% of the visit….time may be considered the key or controlling factor for a particular level of E/M service.

CounselingCounseling is a discussion

concerning one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies

• Prognosis

Counseling, cont.• Risks & Benefits of management

options• Instructions for treatment and/or

follow-up• Importance of compliance with

treatment options

Counseling, cont.• Risk factor reduction• Patient education

Time

• 99201 – 10 min• 99202 – 20 min• 99203 – 30 min• 99204 – 45 min• 99205 – 60 min

• 99211 – Nurse Visit

• 99212 – 10 min• 99213 – 15 min• 99214 – 25 min• 99215 – 40 min

NEW PATIENT & CONSULTATIONS 3 KEY COMPONENTS REQUIREDA new patient is 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 last 3 years.

MEDICAL DECISIONCODE HISTORY EXAM MAKING TIME

99201 99241 Problem Focused Problem Focused Straightforward 10 Min99202 99242 Exp. Problem Focused Exp. Problem Focused Straightforward 20 Min99203 99243 Detailed Detailed Low 30 Min99204 99244 Comprehensive Comprehensive Moderate 45 Min99205 99245 Comprehensive Comprehensive High 60 Min

ESTABLISHED PATIENT 2 KEY COMPONENTS REQUIREDAn established patient is a patient who has received professional services from the physician or another physician of the

same specialty who belongs to the same group practice within the last 3 years.

MEDICAL DECISIONCODE HISTORY EXAM MAKING TIME99211 Nurse Visit 5 Min99212 Problem Focused Problem Focused Straightforward 10 Min99213 Exp. Problem Focused Exp. Problem Focused Low 15 Min99214 Detailed Detailed Moderate 25 Min99215 Comprehensive Comprehensive High 40 Min

Consultation Coding

• Outpatient consultation codes are 99241, 99242, 99243, 99244, and 99245.

• Inpatient consultation codes are 99251, 99252, 99253, 99254, and 99255

Consultations

• The request and need for the consultation must be documented in the patient’s medical record

• All services provided and the resulting “advice or opinion” must be provided in writing to the requesting physician

Consultations, Cont.• Consultation services are

reimbursed at a higher rate than the Out-Patient or In-Patient E & M Services

Initial Hospital Care• Only one physician may submit an

initial hospital care code for the same patient (99221, 99222, 99223)

• Co-Admitting physicians must decide who will bill initial hospital care

• If both do, the first claim received will be paid, with the second rejected

Subsequent Hospital Care

• Hospital visit codes are used to report DAILY services (99231, 99232, 99233)

• Multiple visits on the same day, by the same physician, must be reported as 1 visit with a higher level code incorporating both visits

Concurrent Hospital Care

• Providing similar hospital visits to the same patient..by multiple physicians.. on the same day..with the same diagnosis..will likely be denied

• Avoid using the “admitting” diagnosis• Code for the SPECIFIC reason YOUR

SPECIALTY saw the patient

Hospital “Floor Time”

• Hospital Services (Initial & Subsequent) include the time the physician is present at the patient’s bedside and on the unit to include time spent reviewing the chart, writing notes, exam time, and coordination of the patient’s care

Hospital Discharge

• 99238 - Hospital discharge day management; 30 minutes or less

• 99239 – Hospital discharge day management; more than 30 minutes

ICD9 Coding Defined

• The “reason” for procedures, services, and supplies are converted into ICD9 Diagnosis Codes

• Codes identify diagnosis, symptoms, conditions, problems, complaints or other reasons for service

Suspected Conditions• If a diagnosis is questionable,

probable, likely, or rule out code the signs, symptoms, or complaints

• Avoid reporting a diagnosis code that is not proven…use signs, symptoms, complaints

Complications

• Complications are responsible for many procedures therefore the complication should be coded

• For example:998.5 Postoperative Infection

997.3 Respiratory Complications

Questions ???