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Coding Close To Home

Steven A. Adams, CPC, CPC-H, COA. Coding Close To Home. Doctor & Coder. 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

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Coding Close To Home

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  1. Steven A. Adams, CPC, CPC-H, COA Coding Close To Home

  2. Doctor & Coder

  3. 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

  4. Table of Contents • Medicare Payment Reform • 2003 CPT Coding Changes • Modifiers / Global Surgery Rules • E and M Codes & Changes • Preventive Medicine Services • Home Health & Hospice Coding • Incident To Rules • HIPAA

  5. Medicare Payment Reform Continues Always be nice to your children because they are the ones who will choose your rest home. Phyllis Diller

  6. Conversion Factor Over Time: • 1997 - + 0.6% • 1998 - + 2.3% • 1999 - + 2.3% • 2000 - + 5.5% • 2001 - + 5.0% • 2002 - (- 4.8%) • 2003 - (- 4.4%)

  7. Code 2002 2003 Change99203 91.95 86.86 -6% 99204 130.68 123.89 -5% 99205 166.15 157.46 -5% 99211 20.27 19.03 -6% 99212 36.20 33.91 -6% 99213 50.32 47.76 -5% 99214 78.91 74.75 -5% 99215 115.84 109.35 -6% 99221 65.16 61.94 -5% 99222 108.24 102.78 -5% 99223 150.95 143.27 -5% 99231 32.58 30.80 -5% 99232 53.57 50.87 -5% 99233 76.38 72.33 -5% 99238 66.24 62.98 -5% 99241 47.06 44.64 -5% 99242 87.24 82.36 -6% 99243 115.84 109.35 -6% 99244 164.34 155.38 -5% 99245 212.85 201.41 -5% http://www.cms.hhs.gov/physicians/pfs/cms1204p.zip

  8. CPT 2003 Coding Changes • That it will never come again / Is what makes life so sweet. • Emily Dickinson

  9. 2003 Changes • 204 New codes; • 23 deleted codes; and • 203 revised codes. (not including changes in indexing).

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

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

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

  13. E&M Coding How we spend our days is, of course, how we spend our lives. Annie Dillard

  14. 7 Components First Established 1992 • History • Examination • Decision-making • Counseling • Coordination of care • Nature of presenting problem(s) • Time

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

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

  17. 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

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

  19. My History?

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

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

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

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

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

  25. 1995 Exam 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive

  26. Eye Exam

  27. 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

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

  29. You want to put the thermometer where?

  30. 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

  31. 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

  32. Codes - 435 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

  33. $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

  34. 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

  35. 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

  36. 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

  37. $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

  38. 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

  39. 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

  40. 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

  41. $122 $154 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

  42. 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

  43. 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

  44. 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

  45. $155 $200 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

  46. 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

  47. Auditing Notes • What you might find initially during your audits

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