CODING and BILLINGAm I Being Paid Appropriately?

Sandra M. Nettina, MSN, CRNPPresident, NPAM

Nurse Practitioner, Columbia Medical Practice

CODINGICD-9 International Classification of

DiseasesPublished by United States GovernmentDiagnoses basedAssign codes to your assessment at the highest

level of differentiationCPT Current Procedural Terminology

Copyrighted by American Medical AssociationProcedural rather than disease or disorder

Coding (cont.)ICD-9 codes are used to justify

medical necessity of a serviceCPT codes are used for billingEvaluation and management codes

(E&M) are CPT codes that describe consultations, ER, and office visits

Evaluation and Management Codesnew and established office visit

99201/99211: 10 min. (new) or 5 min. (est.) Presenting problem is self limiting or minor

99202/99212: 20 min. (new) or 10 min. (est.)low to moderate severity

99203/99213: 30 min. (new) or 15 min. (est.)moderate severity

99204/99214: 45 min. (new) or 25 min. (est).moderate to high severity

99205/00215: 60 min. (new) or 40 min. (est.)moderate to high severity

Other EncountersOutpatient consultation: 99241 to

99245 Inpatient consultation: 99251 to 99255Emergency Room: 99281 to 99285Initial hospital observation: 99221 to

99223Subsequent hospital: 99231 to 99233Initial nursing facility: 99304 to 99306Subsequent nursing facility: 99307 to

99310Domiciliary, Rest home, custodial care

Billing

Use E&M codes for Outpatient Visits, Consultations (outpatient and inpatient), ER visits

Calculated by 7 componentsSimilar process for hospital observation, nursing facility, and home care, but will not be discussed

Componentsdetermine E&M coding level—must be documented

Key HistoryExamMedical Decision

Making (MDM)

ContributingCounselingCoordination Nature of

Presenting ProblemTime

HISTORYChief Complaint—required for all level of

visitsHistory of Present Illness (HPI)—brief or

extendedReview of Systems (ROS)—problem focused,

extended, completePast, Family, Social History (PFSH)—

pertinent or completeHow much information is obtained and

documented?

CC and HPIChief complaint is required for all level of

histories: simple statementHPI elements: OLFQQAAT, OLDCART, PQRSTOnset, location, frequency, duration, quality

(character), quantity (severity), aggravating factors, relieving factors (treatments tried), associated factors

REVIEW of SystemsConstitutionalEyesEars, nose, throatCardiac/vascularRespiratoryGIGUMusculoskeletalIntgumentary/breast

NeurologicPsychiatricEndocrineHeme/lymphAllergy/immunology

Past Medical, Family, and Social HistoryPast illnesses, chronic conditions,

surgeries, injuries, hospitalizations, health screening and diagnostic tests

MedicationsRelated family historySocial history—tobacco, alcohol, drugs,

exercise, diet, work, sexual activity

Level of HistoryType of History

CC HPI ROS PFSH

Problem Focused

Required Brief (1-3 elements)

Not required

Not required

Expanded problem focused

Required Brief (1-3 elements)

Problem pertinent

Not required

Detailed Required Extended (4+ elements, or status of 3+ chronic conditions)

Extended (2-9 systems)

Pertinent (1 item from 1 area)

Comprehensive

Required Extended Complete (10+ systems)

Complete (1 item from 2 areas (est.) or 3 areas (new))

Level of History (cont.)Complete ROS—10 or more systems or some

systems with statement “all other systems negative”

Complete PFSH—need 3 for new patients, consultations, hospital observation, initial nursing facility care

Determine the level of history by the column farthest to the left (one poorly documented element can bring the level down).

EXAMBody Area

Head/face, Back/spine, Chest/breast/axilla, Genitalia/groin/buttocks, Abdomen, Neck, Each Extremity

Organ SystemsConstitutional, Eyes, Ears/nose/throat, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neuro, Psych, Heme/lymph/immune

EXAM Problem focused

Expanded problem

Detailed Compre-hensive

Single Organ System 1-5 elements

At least 6elements

At least 12(eye and psych: 9)

All elements

Multi-system Exam 1-5 elements in 1 or more systems

At least 6 elements in 1 or more systems

At least 6 systems with 2 elements each

At least 9 systems with 2 elements each

Medical Decision MakingNumber of diagnoses and treatment

optionsAmount and complexity of data

reviewedRisk of complicationsMorbidity and mortality

Number of Diagnoses and Treatment Options

Problem Status Points

Self limited or minor 1

Established problem (to examiner): stable or improved

1

Established problem (to examiner): worsening 2

New problem (to examiner): no additional work up

3

New problem (to examiner): additional work up planned

4

Add up the scores for all problems to obtain a total. Self limited or minor maximum of 2. New problem with no additional work up maximum of 1.

Amount and Complexity of Data ReviewedReviewed Data Points

Review and/or order of clinical lab tests 1

Review and/or order of radiology 1

Review and/or order of other medical tests 1

Discussion of test results with performing physician 1

Decision to obtain old records or history from someone other than patient

1

Review and summarize old records and/or obtain history from someone else and/or discuss case with another health care provider

2

Independent review of imaging, tracing, or specimen itself

2

Total

Risk of Complications, Morbidity/MortalityMinimal—one self-limited or minor problemLow—2 or more self-limited or minor

problems; 1 stable chronic illness; 1 acute, uncomplicated illness

Moderate—1 or more chronic illness with minor exacerbation; 2 or more stable chronic illnesses; undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; acute complicated injury

Risk (continued)High

1 or more chronic illnesses with severe exacerbation

Acute or chronic illnesses or injuries that may pose a threat to life or bodily function

An abrupt change in neurologic status

Minimal Risk examplesCold, insect bite, tinea corporisOrder blood work, chest xray, ECGRecommend rest, gargles,

superficial dressing

Low Risk Examples2 or more self limited or minor

problems1 chronic illness that is well

controlledAcute illness such as UTI, simple

sprain, allergic rhinitisPFT, skin biopsy, non-cardiac

imagingOTC meds, physical therapy, minor

surgery without risk factors, IV fluid without additives

Moderate Risk examplesOne or more chronic condition, worseningTwo or more stable chronic conditionsAcute illness with systemic symptoms such as

pylonephritis, pneumoniaAcute complicated injury such as concussionNew problem needing additional work upStress test, endoscopy, cardiovascular

imagingMinor surgery with risk factors, prescription

drugs, closed treatment of fracture

High Risk examplesOne or more chronic illness with severe

exacerbation, abrupt change in neuro statusAcute threatening illnesses such as severe

respiratory distress, acute MI, pulmonary embolus, peritonitis, acute renal failure

Invasive tests with identified risk factorsElective surgery with risk factorsDrug therapy requiring intensive monitoringDecision not to resuscitate or de-escalate

care

Summary of Decision MakingSummary of Results of Complexity(Level of Medical Decision Making)

Straight-forward

Low Complex

Moderate Complex

High Complex

Number of diagnoses or treatment options (points)

< 1minimal

2limited

3multiple

>4Exten-sive

Amount and complexity of data (points)

< 1 Minimal or low

2limited

3multiple

> 4exten-sive

Highest Risk minimal

low moderate

High

If all 3 are not at the same level, then level of medical decision making is determined by the second highest indicated.

Established Office VisitLevel 2 (99212)

Level 3 (99213)

Level 4 (99214)

Level 5 (99215)

History Prob-focused

Expanded PF

Detailed Comprehensive

Exam Prob-focused

Expanded PF

Detailed Comprehensive

MDM(complexity)

Straight forward

Low Moderate High

Approximate time

10 min. 15 min. 25 min. 40 min.

Level is determined by at least 2 components in the same level.

Level 1 (99211) is a minimal visit that may be done by ancillary staff

New Patient/ConsultationI II III IV V

History PF EPF Detailed Comp Comp

Exam PF EPF Detailed Comp Comp

MDM SF SF Low Medium High

New patient—Has not had any professional face-to-face services from the provider or any provider in the same specialty in the group in previous 3 years. Requires 3 components on the same level.

Preventative ServicesBy age, coverage and reimbursement are

preset and vary by insuranceMedicare does not cover a routine yearly

physicalWelcome physical in first yearOther preventative services and screenings at

determined intervals Must use appropriate codes

Counseling/Coordination of CareFor an encounter dominated by counseling

about a medical condition or coordination of care, time is a determining factor.For outpatient visit, must be face-to-face timeFor inpatient, can be time on unitTime can be estimatedMust document 3 components: total time, at

least 50% of the visit was spent counseling, nature of the counseling

Incident ToPaid at full physician fee schedule amountNPs and other non-physician providers are

usually allowed at 85%Usually used for follow up of a physician’s

patient following the same plan of care.

Incident To ProvidersAuxiliary personnel: RNs, LPNs, TechniciansNon Physician Providers (NPPs): NP, PA,

CNS, CNM (can supervise auxiliary personnel for payment, except in hospital outpatient departments)

Physical therapists, occupational therapists, clinical social worker

On claim report both name and NPI of initiating physician and supervising physician

RequirementsServices must be furnished in the office (not

hospital)Furnished under direct supervision of a

doctorMust have employment relationship Are integral, although incidental to the

doctor’s services. Commonly rendered without a physician

charge but incur some expense (for dressing change, drug administration)

Direct SupervisionSupervising physician can be any

member of the group Must be present in the office suites

and immediately available.Does not need to speak to or lay

hands on the patient.

Employment RelationshipEmployeeLeased employeeIndependent contractor of physician

or legal entity that employs or contracts physician

Documentation mustIdentify who rendered the serviceIndicate supervision requirement is

metShow physician’s initiation and

continued involvement in treatment plan

Show that care was reasonable and necessary

Show that care was within the scope of practice of NPP

Modifiers25—significant, separate E&M

performed by same provider on same day

24—unrelated E&M done by provider at post operative visit

50—bilateral (pays 150%)51—multiple proceduresDocumentation should show medical

necessity and what was done in addition

Comprehensive Error Rate TestingCMS program monitors accuracy of

claims and paymentsNational error rate is 4.5%Maryland and surrounding states: 4.3%Services associated with errors:

Consults 27% --Established office visits 21%

other outpatient 21%Initial hospital 15% ---Subsequent 13%

Billing and Coding TipDocument every visit using a SOAP note

with subheads and bulleted points for HPI (OLDCART, PQRST), ROS, related past/family/social history, exam by systems, diagnoses, and treatment plan.

You will more easily be able to determine the E&M level, or if you document electronically, a computer program may determine the E&M.

ResourcesCenter for Medicare and Medicaid Services w

ww.CMS.hhs.govwww.cms.hhs.gov/MLNEdWebGuide/25_EMD

OC.aps (Documentation Guidelines)www.cms.hhs.gov/MLNProducts/downloads/19

95dg.pdf (1995 Guidelines)

www.cms.hhs.gov/MLNProducts/downloads/master1.pdf (1997 Guidelines)

www.cms.hhs.gov/manuals (Claims processing)

Resources (cont.)Highmark Medicare Services

www.highmarkmedicareservices.com

www.highmarkmedicareservices.com/faq/partb/index.html (Frequently Asked Questions)

www.highmarkmedicareservices.com/partb/reference/scoresheets.html (E&M score sheets)