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CPT Coding: Beyond the Basics

CPT Coding: Beyond the Basics. AANP NATIONAL CONFERENCE 2010 Barb Pierce, CCS-P, ACS-EM Barb Pierce Coding and Consulting, LLC barbpiercecoder@aol.com. Objectives. Review the overall billing process, including CPT, HCPCS, and ICD-9 coding systems 30 minutes

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CPT Coding: Beyond the Basics

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  1. CPT Coding: Beyond the Basics AANP NATIONAL CONFERENCE 2010 Barb Pierce, CCS-P, ACS-EM Barb Pierce Coding and Consulting, LLC barbpiercecoder@aol.com

  2. Objectives • Review the overall billing process, including CPT, HCPCS, and ICD-9 coding systems • 30 minutes • Review the codes used on a daily basis • 90 minutes • Review surgical coding, proper use of modifiers and other coding concepts • 60 minutes Barb Pierce, CCS-P, ACS-EM

  3. Outline • E/M codes • Office, hospital, consultations, preventive medicine • Injections and immunizations • Lacerations, lesions and other minor surgical procedures • Modifiers • ICD-9 coding and linking • Coding for compliance Barb Pierce, CCS-P, ACS-EM

  4. The codes • CPT • Main coding system that describes what was done • HCPCS • Further specification of some CPT codes, including supplies • ICD-9 • Describe why the service was performed, diagnostic statement Barb Pierce, CCS-P, ACS-EM

  5. Billing the codes • The “what” and the “why” need to be linked and must meet medical necessity • The encounter form (superbill) needs match the information in the medical record Barb Pierce, CCS-P, ACS-EM

  6. Billing for the Provider • Billing rules for the Nurse Practitioner • Own number • Incident to • Medicare versus everybody else • Split/shared visits • Consultations Barb Pierce, CCS-P, ACS-EM

  7. E/M Coding • New vs. established and initial vs. subsequent • What is a new patient? • Determined by site of service • Follow the HCFA/AMA Documentation Guidelines to choose the level Barb Pierce, CCS-P, ACS-EM

  8. New vs. Est Patients • Per CPT: Solely for purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). • Cardiologist read an EKG on a patient a year ago without a face-to-face visit. NP in same group sees the patient on 1/15/10. • New patient Barb Pierce, CCS-P, ACS-EM

  9. New vs. Est Patient • Per CPT: A new patient is one 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. • Dr. FP1 saw the patient for bronchitis six months ago. NP is now seeing the patient for abdominal pain. • Established patient to Dr. FP2 • Dr. Heart (general cardiology) saw the patient for HTN six months ago. Now the patient is seeing Dr. Vessel (interventional cardiology) for coronary artery blockage six months later. • Established patient to Dr. Vessel Barb Pierce, CCS-P, ACS-EM

  10. New vs. Est Patient • Watch for specialty designations, as recognized by Medicare • Example on previous slide, no different specialty designation for Dr. Heart and Dr. Vessel • Dr. Podiatry and Dr. Back in the same Ortho group. These are recognized as different specialties according to Medicare. So, if Dr. Podiatry saw the patient within the past 3 years and now Dr. Back is seeing the patient, Dr. Back could bill a new patient visit. Barb Pierce, CCS-P, ACS-EM

  11. E/M Section • Key components • History • Examination • Medical Decision Making • Some require 3/3 • Some require 2/3 • Coding by time instead Barb Pierce, CCS-P, ACS-EM

  12. Office/Other outpatient services • 99201-99215 • Codes don’t crosswalk, i.e... 99213 compared to 99203 • Office and where else? • 99211 … be careful • Hints for construction of encounter form Barb Pierce, CCS-P, ACS-EM

  13. Consultations 2010 … CPT A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source. The consultant’s opinion and any services that were ordered or performed must be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. Still cautioned about transfer of care Billing for consultations based on new wording “on the unit” Barb Pierce, CCS-P, ACS-EM

  14. Consultations 2010 … Medicare • Medicare has decided not to pay for consultations starting in 2010. Instead the RVU’s have been reallocated and increased for the other visit codes. • Office, use new or established patient visit codes (3 yr rule will apply) • Hospital and Nursing Facility, use admission codes • Office: Codes formerly used for consultation services 99241 – 99245 crosswalk exactly with documentation requirements of 99201 – 99205. If patient seen in last 3 years by physician of same group of same specialty, then use 99212 – 99215. • Hospital and Nursing Facility: Codes formerly used for consultation services 99251 – 99255 do not crosswalk with admission codes (5 levels of consults versus 3 levels of admissions) Barb Pierce Coding and Consulting, LLC

  15. Observation codes • Based on patient status • Admit to OBS 99218-99220 • Discharge from OBS 99217 • What if patient is held in OBS for 3 calendar days? • Admit and discharge from OBS same date 99234-99236 Barb Pierce, CCS-P, ACS-EM

  16. Medicare Coding for OBS patients • Consultations for patients in OBS status • The ordering physician for the OBS status will use the OBS admission codes 99218 – 99220 • The “specialist” will use the outpatient visit codes 99201 – 99215 • Three year rule will apply Barb Pierce, CCS-P, ACS-EM

  17. Inpatient Services • Admission 99221 - 99223 • H/E/MDM similar to 3,4,5 new patient/consult codes • admission from the office…bill the office visit or the initial hospital care? • daily visits without an initial hospital code first • Admit/discharge same date: 99234-99236 Barb Pierce, CCS-P, ACS-EM

  18. Inpatient Admissions • 99221 requires • Detailed history and • Detailed exam and • Straightforward medical decision making • 99222 requires • Comprehensive history and • Comprehensive exam and • Moderate medical decision making • 99223 requires • Comprehensive history and • Comprehensive exam and • High medical decision making Barb Pierce, CCS-P, ACS-EM

  19. Hospital Admissions • No three-year rule • For Medicare, the admission code will be billed by the “physician-formerly-known-as-a-consultant” per hospital admission. Multiple physicians may be billing the 99221 – 99223 on the same patient. Admitting physician of record will use modifier -AI. • Oncologist saw the Medicare patient during an admission six weeks ago. The patient is admitted again, the oncologist is “consulted” again (for the same or a different problem). Oncologist bills 99221-99223. Barb Pierce, CCS-P, ACS-EM

  20. Inpatient Admissions CPT’s intent of 99221 – 99223: Report the first hospital inpatient encounter Not necessarily the date of admission Not used if patient seen subsequently that date and discharged New for 2010, these are the codes recognized by Medicare for all physicians seeing the patient for the first time during a hospital stay Used in place of consultation codes If documentation is less than documentation requirements for 99221, use the unlisted code 99499 or subsequent hospital visit code 99231 – 99233. Admitting physician of record will use modifier -AI Diagnosis coding issues … medical necessity will prevail Barb Pierce, CCS-P, ACS-EM

  21. Modifier for Admitting Physician of Record • What modifier should the admitting physician of record use? • AI is a new HCPCS modifier for “principal physician of record” • Informational modifier • Specialist claims should not be held up if admitting physician of record forgets to use the AI • If AI is used unnecessarily, claims should not deny … no edit in place currently Barb Pierce, CCS-P, ACS-EM

  22. Inpatient Services • Subsequent hospital care 99231 - 99233 • Only need 2/3 key components • Can’t bill for more than one/day • Code by time when appropriate • Discharge: 99238 or 99239 based on time…and what is included in that time Barb Pierce, CCS-P, ACS-EM

  23. Inpatient Discharge • 99238 • Discharge day management, 30 minutes or less • 99239 • Discharge day management, more than 30 minutes • Documentation must indicate that >30 minutes spent and why • Includes: • Final evaluation of the patient • Discussion of hospital stay • Instructions (may include caregivers) • Preparing discharge records, prescriptions and referral forms Barb Pierce, CCS-P, ACS-EM

  24. OBS or Inpatient Care - Admit and Discharge Same Date • Same calendardate • Can be used for OBS or inpatients • Medicare guidelines require that the patient be there at least 8 hours if using these codes and provider must document that fact • Patient could be inpatient status or OBS status … codes are the same, place of service would be different • 99234, 99235, or 99236 (same criteria for history, examination, and MDM as other admission codes) • Require two face-to-face visits • Why? The RVU for these codes = admit + discharge • Face-to-face for one and phone call for other won’t work • If only seen once, then bill for the service rendered, which might be the admit (inpatient or OBS) or it might be the discharge Barb Pierce, CCS-P, ACS-EM

  25. Nursing Facility services • Nursing Facility Codes • Include SNF, even if bed located in hospital setting • Don’t forget the discharge codes 99315-99316 based on time • Hospital discharge and nursing facility admission on same date IF both services meet criteria • For Medicare, the service formerly reported as a consultation will now be reported as an admission to the facility. Barb Pierce, CCS-P, ACS-EM

  26. Domiciliary Services • Facilities without a medical component • Can be used for Assisted Living facilities Barb Pierce, CCS-P, ACS-EM

  27. Emergency Department codes • “organized hospital-based facility”…must be available 24 hours a day • Five levels 99281 - 99285 with different criteria than office visits • Can’t code by time • Specialists should used consultation codes instead, if criteria met (except for Medicare) Barb Pierce, CCS-P, ACS-EM

  28. ER Visits • 99281 – 99285 • Codes usually used by the provider assigned to the ER • Could be possible for more than one provider to use this code on same patient • But … probably a consultation or office/out-patient service instead • However, for Medicare, multiple physicians are to use the ER codes (in place of consultation codes) Barb Pierce, CCS-P, ACS-EM

  29. Medicare Resources • Prolonged Services • MLN Matters MM5972 7/1/08 • http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf • Critical Care • MLN Matters MM5993 7/7/08 • http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf Barb Pierce, CCS-P, ACS-EM

  30. Preventive Medicine • When considering the billing options for preventive medicine, we must keep in mind: • We intend to submit accurate information to health insurers. • We will not misrepresent the nature or purpose of encounters in order to receive insurance reimbursement. Barb Pierce, CCS-P, ACS-EM

  31. Preventive Medicine • When an appointment is scheduled, attempt to determine the nature of the visit so as to allow adequate time for the service. Patient education could occur at that time. • Are you going to take care of everything today and split bill? Barb Pierce, CCS-P, ACS-EM

  32. PM with E/M • Define “additional work” • E/M codes require a chief complaint and history of present illness • From an auditing standpoint, expect additional history and medical decision making Barb Pierce, CCS-P, ACS-EM

  33. CPT Codes 99381-99397 • are for preventive medicine services • are defined by the patient’s age • in two categories: new or established • require comprehensive history and comprehensive examination (but not same definition as comprehensive in E/M Documentation Guidelines) Barb Pierce, CCS-P, ACS-EM

  34. MEDICARE P/P/B • Medicare will pay every two years for a screening pap, pelvic and breast exam for females at low risk • G0101 is for the pelvic and breast exam, requires 7/11 elements on exam • Q0091 is for collection of Pap smear • Paid yearly for patients at high risk • Can bill E/M-25, G and Q on same date Barb Pierce, CCS-P, ACS-EM

  35. G and Q • Use ICD-9 codes V76.2, V76.47, or V76.49 for patients at low risk • Each ones pays $30.00 + • Paid every two years for low risk • If unsure when patient last had these services, get an ABN signed and use -GA modifier Barb Pierce, CCS-P, ACS-EM

  36. E/M, G, and Q • Document and code the E/M service at the appropriate level based on history, exam and decision making. Modifier -25 and diagnosis(es) for problems addressed • Bill the G0101 and Q0091 additionally with V code as diagnosis Barb Pierce, CCS-P, ACS-EM

  37. Medicare Carve Out • 99397 • 9921X-25 • G0101 • Q0091 (?) • Any combination of above, based on documentation • Patient pays 99397 minus Medicare allowed services Barb Pierce, CCS-P, ACS-EM

  38. What about the guys?? • Medicare digital rectal exam G0102 • Medicare PSA G0103 • Here’s the good news: both are paid yearly • Here’s the bad news: both are bundled with E/M code if done on same day Barb Pierce, CCS-P, ACS-EM

  39. Other preventive medicine services • Other than these E/M services, Medicare also pays for other screening, preventive services. • Research your Medicare bulletins • Welcome to Medicare Physical • Much better with 2009 changes • Some screening labs for diabetes and cardiovascular disease Barb Pierce, CCS-P, ACS-EM

  40. E/M Documentation Guidelines • E/M Documentation Guidelines: • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html Barb Pierce, CCS-P

  41. E/M Coding and Auditing • Documentation must support the level of service billed • Service performed vs. level billed vs. level documented • 95 vs. 97 Documentation Guidelines Barb Pierce, CCS-P

  42. General Principles • Record must be complete and legible • Even the signature or identification • Record stands on its own…but can incorporate by reference • Signature log Barb Pierce, CCS-P

  43. 3/3 or 2/3 ?? • Key components = history, examination, and medical decision making • New patient visits, consultations, hospital admits require 3/3 • Established patient visits, daily hospital care require 2/3 Barb Pierce, CCS-P

  44. History • ROS and PFSH can be incorporated by reference by reviewing and updating prior information, noting the date and location of earlier information…but not HPI • Can also incorporate by reference information recorded by ancillary staff or patient • If unable to get history, say why • “all others negative” • “noncontributory” Barb Pierce, CCS-P

  45. Examination • 1995 guidelines are more generic by body system • How do you apply the ’95 exam criteria? • 1997 guidelines are very specific..the “bullets” • numeric requirements must be met • parenthetical examples are for clarification and guidance only • “and” really means “or” Barb Pierce, CCS-P

  46. Medical Decision Making • Based on the average of : • number of diagnoses/management options • data to be ordered/reviewed • risk (nature of presenting problem, diagnostic procedures, management options) Barb Pierce, CCS-P

  47. Medicine Section • Immunizations and injections require 2 codes: the administration and the supply • 96372 with J code (watch for units) • 90471 for one vaccine • 90472 for each additional vaccine • code the actual vaccine additionally Barb Pierce, CCS-P, ACS-EM

  48. Surgery Section • Global surgery package includes pre-op day(s) and post-op days • Medicare Fee Schedule is good resource…some minor procedures have a post-op period Barb Pierce, CCS-P, ACS-EM

  49. Surgery Section • Separate procedure designation … code only if it is the only procedure done. Example: exploratory laparotomy • Bundled with more extensive procedure • May be the approach • Watch for CCI edits (Correct Coding Initiative) which bundle certain services Barb Pierce, CCS-P, ACS-EM

  50. CCI Edits • Published by NTIS and updated quarterly • Other resources may include other coding standards • Misuse of Column 2 with Column 1 • 20550 Injection tendon sheath is a therapeutic injection. If 20520 (removal of foreign body) is done, it would be a misuse if code 20550 is billed to represent injection of local anesthesia to do the 20520 Barb Pierce, CCS-P, ACS-EM

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