USAFP Business-Coding Workshop, March 2006

1. USAFP Business-Coding Workshop, March 2006 DALE R. AGNER, Lt Col, USAF, MC, SFS Commander, 42d Medical Operations Squadron Maxwell AFB, AL 36112 dale.agner@maxwell.af.mil Telephone: (334) 953-7875

2. Overview Procedures Consults Principles of E&M, CPT Office procedures counting for RVUs E.g.Colpos/vasectomy Preventive Visits Well Appts IMR/Readiness Immunizations

3. Top 10 Errors Presumptive Coding Using E/M for global follow-up visit Need diagnostic E-code for initial tx of injury Pregnancy “incidental” (for correct dx) PHAs and other administrative encounters Code annual GYNs with 9938x/9939x Pap collection is Q0091 Injected drugs, not issued to pt by pharmacy (usually J-codes, some C-codes, some S-codes) One up or one down in the E/M. Most provider 99211s could be 99212s based on documentation. Missing CPTs Presumptive coding – coded in ADM, no documentation When a patient returns for f/u in 10 days for small problem (e.g., suture removal), code with E/M 99499 and procedure 99024 For the 1st encounter to treat an injury, need a code describing how injury happened (use E-codes, External Cause of Injury) If the lady is pregnant, but it does not impact care – “pregnancy incidental”, otherwise, for example, if the lady smokes we would need to code 648.4, pregnancy complicated by mental disorder Don’t use office visits or S0610 or S0612 for annual GYN exams Presumptive coding – coded in ADM, no documentation When a patient returns for f/u in 10 days for small problem (e.g., suture removal), code with E/M 99499 and procedure 99024 For the 1st encounter to treat an injury, need a code describing how injury happened (use E-codes, External Cause of Injury) If the lady is pregnant, but it does not impact care – “pregnancy incidental”, otherwise, for example, if the lady smokes we would need to code 648.4, pregnancy complicated by mental disorder Don’t use office visits or S0610 or S0612 for annual GYN exams

4. Consults to FP, from FP Scope of practice not uniformly in clinic (MEPR) Osteopathic manipulation Colposcopy/vasectomy/endoscopy Some derm (e.g. accutane, more complicated office procedures) Not your own patient Need: Request, Reason, Report Must document: What and why on the consult Report provided/sent/communicated to originator

5. Procedures - Medical Necessity A service that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member consistent w/symptoms or dx of the illness or injury under treatment consistent w/generally accepted professional medical standards not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier; and furnished at the most appropriate level, which can be provided safely and effectively to the pt For instance – tattoo removal. Not too many medical necessity indications. There are many procedures that are medically necessary in some circumstances and not in others. For instance, OB ultrasound for possible small for dates is usually medically necessary. An OB ultrasound to determine a fetus’ gender – not usually medically necessary. Generally accepted professional medical standards – prolotherapy. Furnished for convenience – having a C-section so the lady can be back at work at the start of the new college term Most appropriate level – have a vasectomy as office procedure or as APVFor instance – tattoo removal. Not too many medical necessity indications. There are many procedures that are medically necessary in some circumstances and not in others. For instance, OB ultrasound for possible small for dates is usually medically necessary. An OB ultrasound to determine a fetus’ gender – not usually medically necessary. Generally accepted professional medical standards – prolotherapy. Furnished for convenience – having a C-section so the lady can be back at work at the start of the new college term Most appropriate level – have a vasectomy as office procedure or as APV

6. Procedures - General Office visit codes should not be billed the same day as a procedure is performed unless it is the first evaluation for that issue/done day identified a completely separate problem a change in plan Otherwise, when there is no applicable Evaluation and Management (E&M) code - use “holding” office visit code of 99499 for the day of the visit For instance, a patient comes in with toe pain. The doc questions the patient to rule out gout, then gets a good history to rule out broken off sand burr spine (not running around bare foot in Altus Oklahoma), rule out sea urchin spines (not swimming in tropics), does exam and finds inflammed area around top of toe nail – removes ingrowing nail. 99212-25 plus procedure. For example comes in for periodic DM appointment, get a flu vaccination – 99213-25 and 90471 and 90658 For example you come in for a scheduled flex sig but have bleeding (not there when flex sig was scheduled) so change to do colonoscopy. For instance – Allergen immunotherapy – usually the E/M is included in the procedure code so you would not have an E/M with each injection visit. For instance, a patient comes in with toe pain. The doc questions the patient to rule out gout, then gets a good history to rule out broken off sand burr spine (not running around bare foot in Altus Oklahoma), rule out sea urchin spines (not swimming in tropics), does exam and finds inflammed area around top of toe nail – removes ingrowing nail. 99212-25 plus procedure. For example comes in for periodic DM appointment, get a flu vaccination – 99213-25 and 90471 and 90658 For example you come in for a scheduled flex sig but have bleeding (not there when flex sig was scheduled) so change to do colonoscopy. For instance – Allergen immunotherapy – usually the E/M is included in the procedure code so you would not have an E/M with each injection visit.

7. Procedures - General For follow-up visits, if the dx no longer exists (e.g., laceration, neoplasm, cyst) code only V-code for the follow-up visit or suture removal/dressing change Pain Management - is an office visit But nerve blocks done during pain management visits are codable

8. Procedures - Anesthesia - Conscious Sedation Can only be used by surgeon doing procedures Includes monitoring of cardiorespiratory function (e.g., pulse ox, cardiorespiratory monitor, and BP) Must have independent trained observer to assist provider in monitoring patient 99141 Sedation, w or w/o analgesia; IV, IM, inhalation 99142 Sedation, w or w/o analgesia; oral, rectal and /or intranasal If someone other than the surgeon does the administration of the anesthetic, can not use CS. Be sure to collect the trained observer in the additional provider field.If someone other than the surgeon does the administration of the anesthetic, can not use CS. Be sure to collect the trained observer in the additional provider field.

9. Procedures - Surgical Colonoscopy Drain abscess Drain blood from under nail Infant circumcision Remove cerumen Remove foreign bodies (ear, nose, eye, esophagus…) Remove nail Remove warts Strapping/splinting Treatment of fracture (the casting material is HCPCS code) Removal of cast is put on by someone other than in your MTF These are commonly done and coded in the clinics. These are commonly done and coded in the clinics.

10. Procedures - Lab/Rad/Diagnostic Imaging 7xxxx(DI) 8xxxx(Lab) Code if done and interpreted in the clinic e.g., most labs and diagnostic imaging not coded Common exceptions, CLIA waived tests in the table; Diagnostic Ultrasound of Pelvis 76805-76857 in OB clinic