Advanced Primary Coding Help

Steven A. Adams, CPC, CPC-H, COA Advanced Primary Coding Help

Update on CPT 2004 Definition of a new patient Picking the appropriate level of E&M service 99214 & 99215 and when to bill Pre-Ops/consultations Common procedures and their global periods Modifiers - billing E&M and procedure(s) on same day Medicare preventive services Be specific when coding diagnosis Focus on areas for government scrutiny Topics

Doing It Right The First Time!Five Steps to Proper Reimbursement 1. Understand the Guidelines 2. Perform the Service 3. Document What You Did (according to the guidelines) 4. Bill what you documented 5. Collect what you billed

Update on CPT 2004 • Not everything that can be counted counts, and not everything that counts can be counted. • Albert Einstein

2004 Changes More Than 550 Changes -4.5 Decrease in Reimbursement

Avoiding trouble is largely a matter of knowing the rules & remembering your audience.

CPT What you did Here Are The Rules ICD-9 Why you did it

Here’s Your Audience Criminal Justice Field Accountants Biologists “Most individuals do not have training in the health care field.” CMS and OIG

Definition of a New/Established Patient Government, even in its best state, is but a necessary evil; in its worst state, an intolerable one. Thomas Paine

CPT States: Question Would it be appropriate to bill a patient as “New” if a physician changes practices and sees a patient that he/she had previously seen within the past three years while working for another medical group? The physician would not have access to the old medical records unless he/she requested them form the previous medical group. AMA Comment The determining factor in assigning and evaluation and management code for New vs. Established patient is whether the patient received professional services from the physician within the past three years, regardless of the place of service. Thus, if the patient has received professional services from the same physician within the past three years, the patient is considered an established patient, even though the physician has changed medical groups.

1 E&M Coding There are liars, damn liars, and statistics. Mark Twain

7 Components First Established 1992 • History • Examination • Decision-making • Counseling • Coordination of care • Nature of presenting problem(s) • Time

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

Just Do It • New Patients / Consults • Get a Comprehensive History • Do Comprehensive Exam • Select Code Based Upon MDM

Level 1 Level 2 Level 3 Level 4 Level 5 Self limited problem Self limited problem OTC, minor surgery Undiagnosed problem Rx management Endoscopy surgery without risk factors Major surgery risk factors Major surgery with risk factors Complex problem with data review New - Consults

1 History 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive

5,6 History Component 99205 60 • Comprehensive • Chief Complaint • Extended HPI (4+) • Complete Review of Systems (10) • Complete PFSH (3)

History Component 99205 60 • Comprehensive • Chief Complaint • Extended HPI (4+) • Complete Review of Systems (10) • Complete PFSH (3)

1 1995 Exam 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive

7 Examination Component • Comprehensive • 8 System Exam Const: Well Developed Eyes: PERRLA CV: RRR Lungs: CTA Abd: + Bowel Sounds Skin: Warm, Dry Neuro: Intact Psych: A & O X 3

4 Medical Decision Making 1. Straightforward 2. Low Complexity 3. Moderate Complexity 4. High Complexity

4 Table of Risk Presenting Problems Diagnostic Procedures Management Options Level Chest X-Ray Rest Minimum Self-limiting Pulmonary Function OTC Low Uncomplicated Moderate Undiagnosed Stress Tests Rx Endoscopy w/risk Major Surgery w/risk Threat to Life High

Table of Risk Presenting Problems Diagnostic Procedures Management Options Level Chest X-Ray Rest Minimum Self-limiting Pulmonary Function OTC Low Uncomplicated Moderate Undiagnosed Stress Tests Rx Endoscopy w/risk Major Surgery w/risk Threat to Life High

Codes History Exam Decision Making Code Minimal 99202 Exp. Problem Focused Exp. Problem Focused Detailed Low 99203 Detailed 99204 Comprehensive Comprehensive Moderate Comprehensive Comprehensive 99205 High

$57 $81 Codes History Exam Decision Making Code Minimal 99202 Exp. Problem Focused Exp. Problem Focused Detailed Low 99203 Detailed 99204 Comprehensive Comprehensive Moderate Comprehensive Comprehensive 99205 High

8 Table of Risk Presenting Problems Diagnostic Procedures Management Options Level Chest X-Ray Rest Minimum Self-limiting Pulmonary Function OTC Low Low Uncomplicated Moderate Undiagnosed Stress Tests Rx Endoscopy w/risk Major Surgery w/risk Threat to Life High

Codes History Exam Decision Making Code Straightforward 99202 Exp. Problem Focused Exp. Problem Focused Detailed Low 99203 Detailed 99204 Comprehensive Comprehensive Moderate Comprehensive Comprehensive 99205 High

$85 $108 Codes History Exam Decision Making Code Straightforward 99202 Exp. Problem Focused Exp. Problem Focused Detailed Low 99203 Detailed 99204 Comprehensive Comprehensive Moderate Comprehensive Comprehensive 99205 High

Auditing Notes • What you might find initially during your audits

Codes History Exam Decision Making Code Straightforward 99202 Exp. Problem Focused Exp. Problem Focused Detailed Low 99203 Detailed 99204 Comprehensive Comprehensive Moderate Comprehensive 99205 Comprehensive High

Advanced Primary Coding Help