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Billing and Coding Tutorial

Billing and Coding Tutorial. For Swedish First Hill Family Medicine Residents. Generously prepared by Brandy Thomas, MD September 20, 2011. Goals for today. Review components of appropriately documented note and associated level of service Highlight common billing and coding errors

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Billing and Coding Tutorial

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  1. Billing and Coding Tutorial For Swedish First Hill Family Medicine Residents Generously prepared by Brandy Thomas, MD September 20, 2011

  2. Goals for today • Review components of appropriately documented note and associated level of service • Highlight common billing and coding errors • Answer your questions

  3. 4 Key Components • Every encounter is billed based on 4 key components: • Chief Complaint • History • Physical Exam • Medical Decision Making

  4. 4 Key Components CHIEF COMPLAINT

  5. 4 Key Components The first Key Component to billing is the: CHIEF COMPLAINT

  6. Chief Complaint • A chief complaint must be documented at EVERY visit • Must be documented or referred to specifically by the MD (not just an RN/MA)

  7. 4 Key Components The 2nd Key Component is the HISTORY:

  8. History • The History is made of 3 parts: • HPI (history of present illness) • PFSH (past, family, and social histories) • ROS (review of systems) • The billable history level is based on the highest level in which all 3 parts are fulfilled

  9. History The first part of the History is the HPI:

  10. History • HPI • “Elements” = location, severity, quality, context, timing, duration, modifying factors, associated signs and symptoms • “Brief” = • 1-3 Elements • OR comment on 1-2 chronic medical problems • “Extensive” = • 4+ Elements • OR comment on 3+ chronic medical problems • There are NO SHORT-CUTS (HPI must be obtained by MD, not RN/MA/questionnaires)

  11. History The 2nd part of the HISTORY is the PFSH:

  12. History • PFSH • CAN be obtained by RN/MA/questionnaire, but must be reviewed by MD, dated/signed, pertinent points discussed, kept as part of medical record • Past Medical Hx - Social Hx • Major illnesses - Marital Status • Operations - Current Employment • Current medications - Occupational History • Allergies - EtOH or drug abuse • Family Hx • Related to problems in HPI • First Degree relative health status and problems • Hereditary Diseases

  13. History The 3rd part of the HISTORY is the ROS:

  14. History • ROS • Inventory used to uncover signs and symptoms not directly expressed by the patient • Again, may be asked by RN/MA/questionnaire, but must be reviewed by MD, signed and dated, pertinent points discussed with the patient, and kept as part of the medical record

  15. History

  16. 4 Key Components The 3rd Key Component is the Physical Exam: • The Physical Exam is based on 14 distinct Organ systems • Each organ system may be reviewed with a single or multiple bullet points

  17. Physical Exam: The 14 Organ Systems • Constitutional: 3 vitals, general appearance • Eyes:inspection of conjunctiva, pupils, lids, and irisis (PERRLA), fundoscopic exam • ENMT:external appearance of ears and nose, otoscopic exam of EACs and TMs, hearing, nasal mucosa, septum, membranes, lips, teeth, gums, oral mucosa, salivary glands, hard and soft palate, tongue, tonsils, posterior pharynx • Neck: inspection (masses, symmetry, crepitus, tracheal position), thyroid inspection • Chest (breasts):inspection for symmetry, skin changes, galactorrhea, masses, tenderness, fibrous changes • Cardio: PMI, auscultation, LE edema, carotid arteries, abdominal aorta, femoral pulses, pedal pulses • Resp: effort, percussion, palpation, auscultation

  18. Physical Exam:The 14 Organ Systems 8) GI: masses, tenderness, liver, spleen, hernias, anus, perineum, rectum, FOBT 9) GU: (male) scrotum contents (tenderness of cord, testicular massess), penis, DRE; (female) external genitalia, urethra, bladder (fullness, masses, tenderness), cervix, uterus (contour, position, mobility), adnexa (masses, tendernes, nodularity) 10) MSK: inspection/palpation of digits and nails (clubbing, cyanosis, ischemia), exam joints, bones, and muscles of 1+ areas including notation of misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, ROM with notation of pain, crepitus, or contracture, assessment of stability with notation of dislocation, subluxation, laxity, and assessment of muscle strength and tone with notation of atrophy or abnormal movements 11) Skin: inspection (rashes, lesions, ulcers), palpation (induration, subq nodules, tightening)

  19. Physical Exam:The 14 Organ Systems 12) Neuro: gait and station, Cns, DTRs, sensation 13) Psych: judgement, insight, AAOx3, recent and remote memory, mood, affect 14) Heme/Lymph/Immune: lymph nodes in 2+ areas

  20. 4 Key Components The final (4th) Key Component is MEDICAL DECISION MAKING (MDM): MDM is, itself, determined based on 3 separate components: Problems, Data points, and level of risk.

  21. Medical Decision Making The 1st part of MDM is PROBLEM POINTS:

  22. Medical Decision Making: Problem Points

  23. Medical Decision Making The 2nd part of MDM is DATA POINTS:

  24. Medical Decision Making: Data Points

  25. Medical Decision Making The 3rd part of MDM is RISK:

  26. Medical Decision Making: Risk

  27. Medical Decision Making The LEVEL OF MDM is the highest level which has 2 of 3 of the component parts: For example: If 2 problem points, 4 data points, and minimal risk, the level of MDM should be LOW COMPLEXITY, since that's the level with a minimum of 2 of 3 components met.

  28. Putting it All Together: E&M Code Decision Once you have all components of your visit determined, you can choose your E&M Code. Choose the highest level of billing with at least 2 of 3 components met.

  29. Billing on Time (as an attending) You may bill on time alone (see times on E&M table). You must document: 1) Total time spent 2) Document >50% time spent in counseling 3) Identify counseling content Ie; “...15 of 25 min visit spent in counseling regarding diabetes and various treatment options...”

  30. New Patients Overall, same concepts to get to E&M codes (99202-99205 instead of 99212-99215), but need more component details for each. Many tables exist to guide your coding, similar to those seen here.

  31. 10 Common Physician Mistakes & Misconceptions • What's an E code? - ANY 800 or 900 ICD-9 code requires at least one E code - 800 and 900 series are “Injuries and Poisonings” - E codes tell the story of how the acute injury occurred - Eg, M.T. strained his gastrocnemius muscle while doing yoga. These are FUN to read, they have them for injuries doing arts & crafts, laundry, from war operations using flame throwers, bites/stings from almost anything, natural disasters, etc. 844.8 (“Sprain of other specified sites of knee and leg”) E005.1 (“Activities involving yoga”)

  32. 10 Common Physician Mistakes & Misconceptions 2) Can you bill for phone calls? - Theoretically, yes. • If you are coordinating care (ie, talking to a specialist, discussion with L&I case managers, nursing home, setting up home care, etc). - Use E&M code 99499 (“Unlisted E/M Service”) 2) E&M not related to last week or tomorrow’s visit - Use 99441-99443 Bad news – most insurers won’t recognize

  33. 10 Common Physician Mistakes & Misconceptions 3) Billing for 1 visit with 2 problems - Normal visits, list ICD-9 codes in order of most acute/urgent problem to least - IF TWO PAYERS (ie, L&I injury and pt has HealthFirst), create 2 separate encounters, 2 notes, and 2 billing statements (one to L&I for the injuries they are following, and another for HealthFirst for other primary care or chronic medical problems)

  34. 10 Common Physician Mistakes & Misconceptions 4) Billing pregnancy visits: A Global Package - Don't forget, antepartum visits, the delivery, and post-partum visits are billed as a package - Patients seen <5 times for antepartum care have a different code than those seen >5, and yet another for those >8 times - Don't forget to choose “high risk” ICD-9 codes when appropriate (not just v22.0 or v22.1) - If you don't do the delivery, you miss a lot of the payment for the “global” care

  35. 10 Common Physician Mistakes & Misconceptions 5) IUD Insertions - Use a modifier (53) to “IUD Insertion” (58300) if you attempt but are not successful at IUD placement in a visit (theoretically less effort, so get less money) - Use a v25.1 series code for your ICD-9 (“insertion of IUD device”) - If you counsel pt on contraceptive options and insert in the same day, bill 9921(3) (or appropriate E&M) with ICD-9 v25.02 (“general counseling and advice, initiation of other contraceptives”) with modifier 25 and procedure codes - REMEMBER, you need to include a HCPCS code (see later slides) for the IUD itself (Mirena = J7302, ParaGard = J7300) when billing too

  36. 10 Common Physician Mistakes & Misconceptions 6) Ear Wax Removal - Sometimes it's part of a routine visit, but if cerumen is “impacted”, you can bill 25 modifier and procedure (69210) for increased pay - HOWEVER, specifics must be met: Criterion to count as Impacted: • Cerumen impairs exam of significant parts of EAC/TMs • Cerumen is hard and/or dry and causing itching, pain, or hearing problems • Associated with foul odor, infection or dermatitis • Obstruction requires multiple attempts and MD skill to remove Documentation Musts: • Time required for removal • Amount of effort required • Equipment used (at minimum, otoscope and wax curettes)

  37. 10 Common Physician Mistakes & Misconceptions 7) What's a J code? - Found in the HCPCS book (Healthcare Common Procedure Coding System) - J code tells exactly what medication was used/injected (ie, lidocaine, dexamethasone, ceftriaxone, etc.) - Use along with the CPT code for administration of the injection itself (different codes for imms, subcutaneous, intramuscular, intraarticular, etc)

  38. 10 Common Physician Mistakes & Misconceptions 8) Is there a way to know how much a visit or procedure will cost a patient? - Yes, though it may not include insurance adjustments, charity care, etc. - Danni or Mary in the billing office can find it through Epic Pro Billing EPIC > Tools > Billing Tools > Price Inquiry

  39. 10 Common Physician Mistakes & Misconceptions 9) Billing for Well Child Checks - Use an age-specific preventive E&M code - Use with v20.2 (“routine infant or child health check”) - Don't forget, there are now specific v20 codes for infants in the first 1 month of life, by days old - IF you discuss an acute care problem at that same visit, then code as a 99213 (or other appropriate E&M for level of care), use 25 modifier, and then use age-specific preventive E&M Code (use acute problem and preventive ICD-9s)

  40. 10 Common Physician Mistakes & Misconceptions 10) Can I find out if someone has insurance? • Yes, or at least someone in the clinic can (ask a biller) • “Benefits inquiry” inside Epic Visit Navigator - “One Health Port” has information on ALL insurance companies for patients in the state of WA, tells if they have insurance or not, and if active.

  41. Online Resources • AAFP (www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.html) • Many useful tools (common ICD-9 code sheets, sample billing sheets with E&M codes) for family docs • Chart audit tool • Many take-aways for later use and practice management

  42. Online Resources • Kaiser Family Foundation (www.kff.org) • A lot of basic information about insurance (and types), uninsured, payment models, Medicare, and Medicaid, including eligibility • Has tutorials and PowerPoints for each topic • Little direct billing and coding training advice

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