Gastroenterology Workshop: 2006-2007 Policies and Guidelines

1. Gastroenterology Workshop:2006-2007 Policies and Guidelines Sponsored by: NASPGHAN October 20-22, 2006 Buena Vista Palace Resort & Spa Orlando, Florida

2. Presenter: • Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS • 204 E Locust St • Lenzburg, IL 62255 • Fax: (618) 475-3622 • E-mail: askmueller@aol.com

3. American Academy of Professional Coders American Health Care Information Management Association American Gastroenterological Association Member, Speaker and Columnist Illinois Nurses Association NASPGHAN Speaker and Columnist Professional Association of Healthcare Coding Specialists Seminar Leader for McVey Associates, Inc. Credentials and Organizations

4. Coding 101 • Diagnosis Codes • HCPCS Codes • CPT Codes • Evaluation and Management • Procedures • Diagnostic testing • Radiology • Anesthesia • Laboratory • Modifiers

5. Diagnosis Codes • ICD-9-CM (International Classification of Diseases) • World Health Organization is author • Can be 3-5 digit codes depending upon code • For example, abdominal pain is 789.0 but in order to be paid requires a 5th digit indicator as to the quadrant involved. 789.06 is abdominal pain, epigastric area

6. Diagnosis Codes • Establishes the medical necessity for visits and procedures • The first diagnosis code is the primary reason/concern for the visit or the finding of the procedure • No more than 4 diagnosis codes are accepted on a claim form

7. 2007 GI ICD-9-CM CODES

8. 2007 GI ICD-9-CM CODES

9. 2007 GI ICD-9-CM CODES

10. HCPCS • HCFA Common Procedural Coding System • Alpha-numeric codes • Alpha modifiers • Drugs and biologicals • Supplies • Outpatient codes • Accepted by both Medicare and commercial payors

11. CPT • Current Procedural Terminology • AMA is author • 5 digit codes representing visits, procedures, and diagnostic studies • 2 digit modifiers are indicators why claim should be paid • Not all procedures that are performed at a single session can necessarily be billed.

12. CPT • To find out if two or more codes can be billed together, the correct coding initiative (CCI) has to be accessed. Updated quarterly. Download available from: www.cms.hhs.gov/physicians/cciedits

13. New 2007 CPT Code • 91111 Wireless capsule endoscopy, esophagus only

14. Consultations (99241-99255) Authority: • CPT • Revised December 20, 2005 • Effective Date: January 17, 2006 • B3- Section 15506

15. Consultations (99241-99255) A. Consultation versus Visit • Requesting Source which is also documented in both requesting physician/qualified NPP record and consulting physician/qualified NPP record • Opinion or Advice Regarding Specific Problem • Report of Findings to Requesting Physician

16. Consultations (99241-99275) B. Consultation Followed by Treatment • Payment Regardless of Treatment Initiation Unless Transfer of Care Occurs • Consultant May Initiate Diagnostic and / or Therapeutic Services

17. Consultations (99241-99275) D. Requested by Members of Same Group • One Physician in Group May Request Consultation from Another Physician in Same Group • All Criteria for Consultation Must Be Met • NPPs May Request Consultation

18. Consultations (99241-99275) D. Documentation • Request and Medical Necessity Must Be In Patient Medical Record • Request May Be in Orders or Progress Note • A Written Report Must Be Furnished to the Requesting Physician

19. Consultations (99241-99275) E. Preoperative Clearance • For New or Established patient • Performed by any Physician • At the request of a Surgeon • Primary Diagnosis V72.81 – V72.84

20. New Patient Visits • Patient is self-referred, not sent from another physician • Letter/documentation back to attending physician not a requirement • Over three years since patient last seen in your practice (exception for Medicaid-once seen by your practice, always established patient except for consultations)

21. Critical Care Visits • At least 30 minutes per calendar date • Time must be documented in either start-stop or total time • Must be based on critical care diagnosis, i.e.; hemorrhagic shock, respiratory failure, septic shock, liver failure, heart failure, etc. • Billed in 30 minute increments

22. Evaluation & Management Services • Based on three components: • History • Physical Exam • Decision Making • Only based on time if more than 50% of the visit is dedicated to counseling and/or coordination of care

23. History • Can be completed by anyone, i.e.; patient, staff, family, physician/provider • Must be reviewed by the physician/provider • If unable to obtain information from the patient due to mental status or level of consciousness, this must be indicated in the patient’s chart.

24. History • History of Present Illness • Past History • Past Medical History • Family History • Social History • Review of Systems

25. History of Present Illness • Each patient has to have a chief complaint documented on each visit whether office or facility • Includes location, quality, timing, severity, duration, context, modifying factors, associated signs/symptoms • Also includes status of active or inactive conditions

26. PFSH (Past, Family, Social, History) • Past: • Medications, Surgeries • Allergies • Immunization status • Family • Social • Marital status, children, • Living situation, employment status • Tobacco, alcohol, recreational/illicit drugs

27. Review of Systems • 14 systems as defined by AMA • At least 10 have to be reviewed for moderate and high complexity visits • Can’t just say ROS is negative or non-contributory • Positive symptoms have to be addressed/documented

28. Physical Examination Requirements 1995 vs. 1997 Guidelines

29. Guidelines

30. Guidelines • Can’t just say complete physical exam is negative or eyes negative • Have to indicate what part(s) of the system were negative • Can’t just be reviewed from previous visit • Does not have to be repeated on follow-up visits unless necessary to decide plan of care for that visit

31. Medical Decision Making The Key to Accurate Reimbursement

32. Medical Decision Making THREE COMPONENTS • Presenting Problems • Diagnostic Testing Ordered • Table of Risk TWO OF THREE COMPONENTS HAVE TO MATCH TO DETERMINE THE LEVEL OF DECISION MAKING

33. Table of Risk • Developed on 1991and is still a current application • The Highest Level from any one column determines the Overall Risk to the Patient • Only one component of decision making