Getting It Right the First Time Coding and Documentation - 2013 steve.adams@ingaugehsi

1. Steven Allen Adams Getting It Right the First TimeCoding and Documentation - 2013steve.adams@ingaugehsi.com

2. Discussion Points • Incident To • E and M Coding for: • Office Visits • Pre-operative Consultations • Modifiers • E/M Only • Surgery Only • Global Periods • Preventive Services • Transitional Care Management

3. Incident To

4. Incident To Billing Using MD # 4 standard criteria for Incident To: • Physician must be in office • Must be an established patient • Must not change anything from previous plan of care • Doctor should see patient every 3rd or 4th visit (shows active participation)

5. E&M Coding

6. Code Selection Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

7. A Word on “Cloning” Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This “cloned documentation” does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.

8. Office – Outpatient Services

9. Outpatient Visit New / Consults 99201 - 99245 “Requires All Three Key Elements”

11. New Patient Definition A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

12. New Patients – Think: • 99202 – No treatment • 99203 – Short term meds, OTC, minor surgery • 99204 – Long term meds, major surgery • 99205 – Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

13. Initial Visits

14. Importance of History • Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements. • Staff can do the past medical history, family history, social history but we expect the provider to do the chief complaint in the history of present illness

15. Unable To Obtain History The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

16. Normal and Negative For the examine and the review of system(s) related to the presenting problem - do not describe as "normal" or "negative."

17. Other Issues Extended HPI – 4 HPI or Status of 3+ chronic or inactive conditions. Complete ROS (lots of questions on the ROS.

18. 1995 – Comprehensive (8) • Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. • Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. • ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. • Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. • Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. • Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. • Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. • Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. • GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

19. What Doesn’t Count (8) - 1995 • Head • Neck • Thyroid • Abdomen • Extremities • Back • Under the 1995 Guidelines CMS and the AMA want you to examine “ORGAN SYSTEMS” and not body areas with regard to any code with the number (8) in the exam criteria

20. Expanded vs. Extended • The difference is not the number of systems examined. Two to seven systems are required for both examinations. • The difference is the detail in which the examined systems are described.

21. 1995 – Detailed 4-7 (4x4) • Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. • Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. • ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. • Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. • Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. • Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. • Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. • Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. • GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

22. 1997 “Bullet Guidelines” • Allow you to document systems and areas, however you have to be very specific about what you document about those systems and areas. • Most EMRs are based on the 1997 guidelines but are not compliant

23. 1997 Guidelines - Correct • EYES: [ ] Sclera white, conjunctive clear. Lids are without lag. [ ] PERRLA. • ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink / symmetric. • This would be 5 bullets and compliant

24. 1997 Guidelines – Not Correct • EYES: [ ] Sclera white, [ ]conjunctive clear. Lids are without lag. [ ] PERRLA. • ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. [ ] Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink [ ] Lips symmetric. • This would be 8 bullets and not compliant

25. What To Do • I’ll have a copy of those guidelines posted on my web site and I’ll give you a link on medicalofficeblog.com • Make sure that you are only getting credit for what the government says you get credit for documenting. • THIS IS A CRITICAL COMPONENT OF YOUR EMR COMPLIANCE

26. New Patients – Think: • 99202 – No treatment • 99203 – Short term meds, OTC, minor surgery • 99204 – Long term meds, major surgery • 99205 – Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

27. Outpatient Visit Established Patient 99211 - 99215 “Requires Two of Three Key Elements”

28. Established Patients – Think: • 99212 – One stable condition • 99213 – Two stable or one unstable problem • 99214: • 3 chronic stable on meds • 2 unstable on meds • 1 stable and one unstable on meds • 99215 – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

29. Established Visits

31. Counseling Dominated 3 standard criteria for time: • Total Face-to-Face time of provider • That more than 50% was counseling • Topics you discussed “If the level of care is being based on time spent with the patient for counseling/coordination of care documentation should support the time for the visit and the documentation must support in sufficient detail the nature of the counseling”

32. Signature Requirements • Make sure you properly SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have the provider’s signature. If the provider is initialing this documentation he/she must also print their name by the initials or  circle the typed name on an office form . This lets the reviewer clearly see that who documented the medical record.

33. Established Patients – Think: • 99212 – One stable condition • 99213 – Two stable or one unstable problem • 99214: • 3 chronic stable on meds • 2 unstable on meds • 1 stable and one unstable on meds • 99215 – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

34. Hospital – Inpatient / Outpatient

36. Time - 99239 Per Change Request 5794, the Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Therefore, the time must be spent with the patient.

37. Observation Coding

41. The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making documentation in the medical record shall include: Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours; Documentation identifying the billing physician was present and personally performed the services; and Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.

42. When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario.

43. In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

44. Modifiers

45. Global Period • 0-10 days = minor (-25 on E&M) • 90 days = major actually 92 days (-57 on E&M) • MMM = maternity codes • XXX = global concept doesn’t apply (x-ray/lab) • YYY = up to carrier (unlisted codes) • ZZZ = always included in global of another service (add on codes)

46. 24 – Unrelated E&M 25 – E&M and minor surgery same day 57 – E&M day before or day of major surgery E&M Only Modifiers Use of the 25 modifier means the procedure note is separate from the E&M note

47. 58 – Anticipated at time of initial procedure 78 – Related to initial procedure 79 – Unrelated to initial procedure Surgery Only Modifiers Use of the 78 modifier means the second procedure will be reduced

48. The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. His documentation states, "Pre-op dx: Painful left ovarian cyst. Procedure in order performed (two auxiliary ports): • 1. Diagnostic Laparoscopy – 49320 (8.38 RVU) • 2. Left ovarian cystectomy – 58662 (19 RVU) •   3. Sharp dissection of adhesions from sigmoid to left adnexa – 58660 (17.94 RVU) • A. 58662, 58660, 49320 • B. 58662-22 • C. 58662, 58660-59, 49320-59 • D. 58662, 58660-51, 49320-51 • 78 y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: • A. 99213-25, 11200 • B. 11200 • C. 99213, 11200-25 • D. 99213-57, 11200-25 • 25 y/o male playing football at a family reunion when he felt his leg “snap.” The patient presents to emergency room and is diagnosed with a closed Tib/Fib fracture of the right leg. Pt is evaluated in the ER by an orthopedic surgeon at the request of the ER attending and fracture is set by Orthopedic physician: • A. 99243-22 • B. 99243-25, 27750 • C. 99243-57, 27750 • D. 27750 • Patient presents to the Dermatologist with a “benign” lesion on their right leg. The lesion is excised (11402) and layered closure is performed (12031) on February 1st. One week later the patient returns to have their sutures removed. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: • A. 99213-24-25, 17000 • B. 99213-24,25, 17000-79 • C. 17000 • D. 99213-25, 17000-51 • While in the global period of the Tib/Fib fracture (which was repaired by the orthopedic surgeon), the patient presents to his primary care doctor for evaluation of lower back pain: • A. 99213-24 • B. 99213-25 • C. 99213 • D. 99213-79 • 68 y/o woman present to OBGYN for annual exam. She is not at high risk for cervical cancer and has had her covered breast and pelvic examination performed last year. You had the patient sign an ABN prior to procedure being furnished. During this examination, the physician also addresses her HTN, OA, DM and CHF. Her physician performs an office visit, pap smear and pelvic/breast examination. Her secondary insurance company does cover preventive services: • A. 99215 E&M and Minor Surgery 78 y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: A. 99213-25, 11200 B. 11200 C. 99213, 11200-25 D. 99213-57, 11200-25 • B. 99214-GV-Q5 • C. 99214-79 • D. 99214-Q6 • A child was admitted for an obstructed airway. The physician performed an immediate diagnostic flexible bronchocospy (31622 – 4.02 RVU). Two transbronchial lung biopsies of abnormal tissue were taken. One from the superior lobe (31628 – 5.28 RVU) and another from the middle lobe (+31632 – 1.52 RVU). In addition, a small tiny “Lego” head was found lodged in the inferior lobe and was removed (31635 – 5.34 RVU). Select the professional CPT code(s) for this procedure: • A. 31622, 31628, 31635 • B. 31632-51, 31635-51, 31628-51 • C. 31628, 31632-51, 31635-51 • D. 31635, 31628-51, 31632 • 10.A diabetic patient undergoes surgery for removal of gangrenous toe (28825). During the postoperative period, it becomes necessary to amputate the entire foot (28800). • A. 28800-78 • B. 28800-79 • C. 28800-58 • D. 28800 • 11.A patient underwent colonoscopy with multiple biopsies (45380) earlier in the day. Four hours later, the patient returns to the office with rectal bleeding and is taken back to the endoscopy suite to control bleeding from the biopsy sites (45382). Code for these procedures: • A. 45380, 45382-58-59 • B. 45382 • C. 45380-57. 45382-24-78 • D. 45380, 45382-78-59 • 12.Steve did some auditing work one-day for a GI doctor in Albany. The audit was less than favorable for this respected physician in the community. Shortly after the audit, Steve found himself eating dinner in Albany at one of his favorite Italian restaurants. At some point in the meal, Steve began to vomit profusely and was rushed to a local hospital. The GI doctor on call that night was, you guessed it, our respected GI doctor who had failed so miserably on his audit. Upon recognizing Steve, the doctor immediately orders both a diagnostic upper GI and diagnostic lower GI. To make matters worse, our GI doctor did these procedures at separate sessions. • After these procedures, Steve never found poor documentation in that physician’s notes again. They both lived happily ever after. • A. 45378, 43235-78 • B. 45378, 43235-79 • C. 45378, 43235-79 • D. 45378, 43235-51 • A 56 y/o morbidly obese female is in need of a Total Abdominal Hysterectomy (TAH) (58150). Two surgeons from the same group work perform this surgery. How would the primary surgeon – surgeon A bill as well as the assistant surgeon B. • A. Surgeon A – 58150, can’t bill assist for Surgeon B because in they are in same group • B. Surgeon A – 58150 // Surgeon B 58150-80 • C. Both Surgeons A and B bill 58150-80 • D. Surgeon A – 58150-62 // Surgeon B bills 58150-80 • While on a skiing vacation in Colorado, Steve fractures his femur and requires emergency surgery to treat this fracture (27507). Ten days later Steve returns home and has four follow-up visits by his local orthopedic surgeon. How should his first visit be coded by the Orthopedic surgeon in Steve’s hometown for post-op management? • A. 99213-24 • B. 27507-55 quantity of 80 • C. 27507-54 quantity of 10 • D. 27507-55 • Dr. Brooks provides the new occult blood test that uses an immunoassay determination (82274) instead of a guaiac determination (82270). Over the last three months the code 82274 is being denied and not covered. What is the correct way to bill for this service? • A. 82270-22 • B. 82274-QW • C. 82274-26 • D. 82272-22 • Dr. Clark is in an county designated by his carrier to be a HPSA. He provides a office visit and EKG. How would he code for this to ensure he receives his 10% HPSA bonus. • A. 99213-26, 93000-26 • B. 99213-AQ, 93000-AQ • C. 99213-26-AR, 93000-AR • D. 99213, 93000

49. The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. His documentation states, "Pre-op dx: Painful left ovarian cyst. Procedure in order performed (two auxiliary ports): • 1. Diagnostic Laparoscopy – 49320 (8.38 RVU) • 2. Left ovarian cystectomy – 58662 (19 RVU) •   3. Sharp dissection of adhesions from sigmoid to left adnexa – 58660 (17.94 RVU) • A. 58662, 58660, 49320 • B. 58662-22 • C. 58662, 58660-59, 49320-59 • D. 58662, 58660-51, 49320-51 • 78 y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: • A. 99213-25, 11200 • B. 11200 • C. 99213, 11200-25 • D. 99213-57, 11200-25 • 25 y/o male playing football at a family reunion when he felt his leg “snap.” The patient presents to emergency room and is diagnosed with a closed Tib/Fib fracture of the right leg. Pt is evaluated in the ER by an orthopedic surgeon at the request of the ER attending and fracture is set by Orthopedic physician: • A. 99243-22 • B. 99243-25, 27750 • C. 99243-57, 27750 • D. 27750 • Patient presents to the Dermatologist with a “benign” lesion on their right leg. The lesion is excised (11402) and layered closure is performed (12031) on February 1st. One week later the patient returns to have their sutures removed. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: • A. 99213-24-25, 17000 • B. 99213-24,25, 17000-79 • C. 17000 • D. 99213-25, 17000-51 • While in the global period of the Tib/Fib fracture (which was repaired by the orthopedic surgeon), the patient presents to his primary care doctor for evaluation of lower back pain: • A. 99213-24 • B. 99213-25 • C. 99213 • D. 99213-79 • 68 y/o woman present to OBGYN for annual exam. She is not at high risk for cervical cancer and has had her covered breast and pelvic examination performed last year. You had the patient sign an ABN prior to procedure being furnished. During this examination, the physician also addresses her HTN, OA, DM and CHF. Her physician performs an office visit, pap smear and pelvic/breast examination. Her secondary insurance company does cover preventive services: • A. 99215 E&M in Global One week later the patient returns for follow-up visit for his elevated BP and to have the skin tag sites examined. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and changes the BP medicine and then destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit: A. 99213-24-25, 17000 B. 99213-24,25, 17000-79 C. 17000 D. 99213-25, 17000-51 6 • B. 99214-GV-Q5 • C. 99214-79 • D. 99214-Q6 • A child was admitted for an obstructed airway. The physician performed an immediate diagnostic flexible bronchocospy (31622 – 4.02 RVU). Two transbronchial lung biopsies of abnormal tissue were taken. One from the superior lobe (31628 – 5.28 RVU) and another from the middle lobe (+31632 – 1.52 RVU). In addition, a small tiny “Lego” head was found lodged in the inferior lobe and was removed (31635 – 5.34 RVU). Select the professional CPT code(s) for this procedure: • A. 31622, 31628, 31635 • B. 31632-51, 31635-51, 31628-51 • C. 31628, 31632-51, 31635-51 • D. 31635, 31628-51, 31632 • 10.A diabetic patient undergoes surgery for removal of gangrenous toe (28825). During the postoperative period, it becomes necessary to amputate the entire foot (28800). • A. 28800-78 • B. 28800-79 • C. 28800-58 • D. 28800 • 11.A patient underwent colonoscopy with multiple biopsies (45380) earlier in the day. Four hours later, the patient returns to the office with rectal bleeding and is taken back to the endoscopy suite to control bleeding from the biopsy sites (45382). Code for these procedures: • A. 45380, 45382-58-59 • B. 45382 • C. 45380-57. 45382-24-78 • D. 45380, 45382-78-59 • 12.Steve did some auditing work one-day for a GI doctor in Albany. The audit was less than favorable for this respected physician in the community. Shortly after the audit, Steve found himself eating dinner in Albany at one of his favorite Italian restaurants. At some point in the meal, Steve began to vomit profusely and was rushed to a local hospital. The GI doctor on call that night was, you guessed it, our respected GI doctor who had failed so miserably on his audit. Upon recognizing Steve, the doctor immediately orders both a diagnostic upper GI and diagnostic lower GI. To make matters worse, our GI doctor did these procedures at separate sessions. • After these procedures, Steve never found poor documentation in that physician’s notes again. They both lived happily ever after. • A. 45378, 43235-78 • B. 45378, 43235-79 • C. 45378, 43235-79 • D. 45378, 43235-51 • A 56 y/o morbidly obese female is in need of a Total Abdominal Hysterectomy (TAH) (58150). Two surgeons from the same group work perform this surgery. How would the primary surgeon – surgeon A bill as well as the assistant surgeon B. • A. Surgeon A – 58150, can’t bill assist for Surgeon B because in they are in same group • B. Surgeon A – 58150 // Surgeon B 58150-80 • C. Both Surgeons A and B bill 58150-80 • D. Surgeon A – 58150-62 // Surgeon B bills 58150-80 • While on a skiing vacation in Colorado, Steve fractures his femur and requires emergency surgery to treat this fracture (27507). Ten days later Steve returns home and has four follow-up visits by his local orthopedic surgeon. How should his first visit be coded by the Orthopedic surgeon in Steve’s hometown for post-op management? • A. 99213-24 • B. 27507-55 quantity of 80 • C. 27507-54 quantity of 10 • D. 27507-55 • Dr. Brooks provides the new occult blood test that uses an immunoassay determination (82274) instead of a guaiac determination (82270). Over the last three months the code 82274 is being denied and not covered. What is the correct way to bill for this service? • A. 82270-22 • B. 82274-QW • C. 82274-26 • D. 82272-22 • Dr. Clark is in an county designated by his carrier to be a HPSA. He provides a office visit and EKG. How would he code for this to ensure he receives his 10% HPSA bonus. • A. 99213-26, 93000-26 • B. 99213-AQ, 93000-AQ • C. 99213-26-AR, 93000-AR • D. 99213, 93000

50. Preventive Medicine Services