Coding 101: Getting Paid for What You Do

1. Coding 101:Getting Paid for What You Do Jeannine Z. P. Engel, MD Assistant Professor of Medicine Vanderbilt University Medical Center

2. Background • HCFA, now CMS (Center for Medicare and Medicaid Services) issued guidelines for documentation of different service codes in 1995. They were revised in 1997. Either can be used. • In general, the 1995 guidelines are more favorable for General Internists. • This presentation will focus on 1995 guidelines.

3. Why should we care? • Individual Benefits • Thought vs. Action: General IM reimbursement traditionally lower than procedure-based specialties • Getting paid for what we do - reimbursement for practice groups and individuals can increase • “Playing the game” vs. “Changing the game”

4. Disclaimer • This presentation will provide basic information regarding documentation and coding. Before applying this information at your institution or practice site, YOU MUST CHECK WITH YOUR COMPLIANCE OFFICE or LOCAL MEDICARE CARRIER to be sure these general principles are appropriate for your practice situation.

5. Learning Objectives • Review documentation requirements for basic outpatient office visits, including Annual Exams • Learn efficient documentation of Medical Decision Making • Discuss appropriate use of Office Consultation by General Internist • Gain comfort in coding levels 3, 4, 5 return office visits

6. Basic CodingRules and Regulations

7. New vs. Return • A new patient has not received professional services from you or a member of your group in any service location (e.g. hospital) in the past 3 years • Multi-specialty groups: variable • If established patient has not been seen in 3 years, bill them as New

8. Elements for E&M visits • History • Chief Complaint (CC) • History of Present Illness (HPI) • Review of Systems (ROS) • Past, family, and social history (PFSH) • Exam • Number of organ systems (1995 guidelines) • Medical Decision Making (MDM) • # diagnoses or management options • Amount of data/complexity • Risk level to patient

9. New Patient- outpatient visit3/3 needed

10. New Outpatient Visit

11. History Chief Complaint History of Present Illness (7) Location Quality Severity Duration Timing Modifying Factors Associated signs and symptoms Elements for E&M visits

12. History Chief Complaint History of Present Illness Review of Systems (14) Constitutional-fever/wt Eyes Ears/nose/mouth/throat CV Respiratory GI GU Musculoskeletal Skin Neurologic Psychiatric Endocrine Heme/lymphatic Allergic/immunologic Elements for E&M visits

13. Elements for E&M visits • History • Chief Complaint • History of Present Illness • Review of Systems • Past, Family, and Social History • Past Medical History • Family history • Social history

14. Pearls for documenting History • Can refer to previously documented elements: “Problem list updated as part of today’s visit” • “All other systems reviewed and negative” may be used in most cases to document negatives. • Taking history from someone other than the patient increases level of medical decision making. • Single bullets satisfy PFSH requirements - does not need to be exhaustive

15. History Exam # of organ systems (12) Constitutional-VS, general appearance Eyes Ears, nose, mouth, throat Cardiovascular (inc edema) Respiratory GI GU Musculoskeletal Skin Neurologic Psychiatric Heme/lymph/immuno-logic Elements for E&M visits

16. Physical Exam • How many organ systems can you document before you lay a stethoscope on your patient??

17. Physical Exam • SEVEN!! • General appearance • Eyes - sclera anicteric/injected • HENT - hearing intact (hard of hearing) • MSK - normal gait/limping • Psych - normal (depressed/flat) affect • Skin - no rash on face, arms • Immunologic - NKDA (use for PMH or PE)

18. Coding New Patient Visits • Need 3 of 3 elements documented (history, exam, decision making) • MDM and MEDICAL NECESSITY SHOULD DRIVE CODING

19. MDM and MEDICAL NECESSITY SHOULD DRIVE CODING

20. Coding Return Patient Visits • Only need 2 of 3 elements documented to meet level of service coded (History, PE, MDM) • MDM and MEDICAL NECESSITY STILL DRIVE CODING

21. Return Patient- outpatient visit2/3 needed

22. Return Outpatient Visit

23. DocumentingMedical Decision Making The Real Meat of Internal Medicine

24. Medical Decision Making • Diagnoses • Data • Risk

25. Medical Decision Making • Number of diagnoses • Number and type of presenting problems • Amount/complexity of data reviewed • Ordering tests and reviewing of tests • Obtaining records or history from others • Overall risk of complications to patient before seeing another medical professional • See “Table of Risk”

26. Number of Diagnoses • Self-limited or minor: 1 point each (2 max) • Established problem, stable: 1 point • Established problem, worsening: 2 points • New problem, no addt’l workup: 3 points • New problem, with further workup: 4 points • Complexity (and thus level of service) • Straight-forward=1; Low=2, Moderate=3, High=4

27. Amount and Complexity of Data • Review and/or order of clinical test: 1 point • Basically all labs • Review and/or order of radiology: 1 point • Review and/or order of medical test: 1 point • Includes vaccines, ECG, echo, PFTs • Discussion of test with performing MD: 1 point • Independent review of test: 2 points • Old records or hx from another person • Decision to do this: 1 point • Doing it and summarizing: 2 points

28. Overall Risk Table • Learn and Love the overall risk table • 3 categories: presenting problem, dx procedures, management options • Highest level of risk in ANY of the 3 categories is the overall risk level for that patient

29. Overall Risk Table • Pearls: • Prescription drug management: moderate • 2+ stable chronic illnesses: moderate • Abrupt mental status change: high • 1 chronic illness w/ severe exacerbation: high

30. Overall Decision Making TableNeed 2 of 3 elements to qualify for given level

31. Counseling, Annual Examsand Office Consultation

32. Counseling • When time spent counseling >50% of total visit, then TIME becomes the deciding factor for coding • Total billing physician face to face time • 99213: 15 min • 99214: 25 min • 99215: 40 min • Must document time spent and reason for counseling

33. Counseling is: • “A discussion with the patient and/or family concerning one or more of the following areas”CPT book • Recommended tests, diagnostic results, impressions • Prognosis • Risks/benefits of treatment (management) options • Instructions for treatment (management) options and follow up • Importance of compliance with treatment (management) options • Risk factor reduction • Patient and family education

34. Preventative Service Visits • NO Chief complaint or HPI • MUST HAVE • Comprehensive ROS (10 organ systems) • Comprehensive or interval PFSH • Comprehensive assessment of risk factors appropriate to age • Multi-system physical exam appropriate to age and risk factors (RF) • Assessment/Plan which includes counseling, anticipatory guidance and RF reduction

35. Preventative Service Visits • New vs. Return rules are the same • Coding based on age of patient • NO specific guidelines for what to include with each age group • Documentation of anticipatory guidance/risk factor reduction is the common missing element • Can refer to previous ROS, PMH, FH, etc.

36. Outpatient Consultation • Consultations require: • A request from another provider • The provision of a consultation evaluation service • A report of the service to the requesting provider • Simply put, one provider asks a question, and the consultant answers it.

37. Consultation Requirements • New CMS requirements as of Jan 2006: • The written request for a consultation must be included in the requesting provider’s plan of care. • A consultation request may be written on an order form in a shared medical record. • The consultant must also document the reason for the consultation. • The “Question” must be documented in 2 medical records

38. Consultation Requirements • The written report may be part of a common medical record or in a separate letter to the requesting provider and must be readily available. • The written report must include the findings and recommendations (the “answer” to the original provider’s question.) • The consultant is expected to have expertise beyond that of the requesting provider.

39. Coding Outpatient Consultations • CPT codes 99241-99245 • Documentation requirements are identical to New Patient visit codes • Outpatient Consult F/U codes were deleted in Jan 2006

40. Pre-Operative Consultations • This is the most common scenario for a General Internist • You CAN bill Consultation on an established patient, as long as all the criteria are met • CMS rules state: “a pre-operative consultation at the request of a surgeon is payable if the service is medically necessary and not routine screening.”

41. Pre-Operative Consultations • Following a pre-operative consultation, if the same MD/NPP assumes responsibility for management of all or part of the patient’s care postoperatively, the subsequent visit codes must be used. • Example – IM performs preop consult for patient prior to surgery; surgery occurs and surgeon requests IM inpatient MD to provide post operative care, in this scenario the inpatient IM MD cannot bill a second consult.

42. Second Opinions - Outpatient • For 2nd opinion evaluations in the outpatient or office setting, report the appropriate Office or other outpatient codes (new or established patient) for the level of service performed. • Confirmatory Consultation codes were deleted in Jan 2006

43. Consults Within a Group • Payment will continue to be made for a consultation if a provider in a group practice requests a consultation from another MD in the same group practice when the consulting MD has expertise in a specific medical area beyond the requesting professional’s knowledge.

44. You have the Basics Let’s apply them to some real cases!

45. Case #1 • CC: 55 yo woman (known to you) presents with back pain • Level 3, 4, or 5? • Depends on: • medical necessity • what is done • what is documented

46. Case #1 • CC: 55 yo woman (known to you) presents with back pain • HPI • Patient awoke 1 week ago with constant, sharp, moderately-severe LBP assoc w/ intermittent spasms. Improves w/ ibuprophen. Remote history of similar sx. No trauma, fevers, weakness, bowel or bladder sx.

47. Case #1 (cont’d) • Exam • Gen: BP 110/60 • Back: lumbar paraspinous tenderness • Assessment • LBP, probably muscular • Plan • Continue ibuprofen • Begin cyclobenzaprine 10mg TID prn • Return in 2 weeks if not better, sooner prn

48. Outpatient Established Patient Hx: location, quality, severity, duration, timing, modifying factors (or status of 3) *Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215) Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4 Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

49. Outpatient Established Patient Hx: location, quality, severity, duration, timing, modifying factors(or status of 3) *Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215) Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4 Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

50. Case #1 - Modification AMore Documentation • Add reference to PFSH (PMH, FH, or SH) • “Problem list and medications reviewed, see summary page” OR • 50 yo woman with HTN OR • 50 yo non-smoker OR • Patient with NKDA OR • Meds-Premarin