CPT Coding and Why You Care

1. CPT Codingand Why You Care Ted A. Bonebrake, M.D.

2. CPT Coding • Current Procedural Terminology • System of coding medical encounters for billing purposes in the US • First published by AMA in 1966 • Updated annually on January 1

3. CPT Coding • E & M Codes (Evaluation and Management) • Procedural Codes • Pathology, Laboratory, Radiology

4. CPT Coding Why do we care? • Correct coding results in correct reimbursement • Coding errors can result in claim rejection, rebilling and delayed reimbursement • Providers are responsible for errors • Incorrect coding may result in charges and fines

5. Reimbursement • Most family physicians today are employees of a clinic or hospital system • Part or all of physician compensation is based on production.

6. Reimbursement • Salaries and/or bonuses are typically based on production which is determined one of two ways: • Gross receipts minus overhead • RVU’s (Relative value units) • Either method is ultimately determined by the CPT codes that a provider bills for.

7. Incorrect Coding • False Claims Act 1986 • HIPAA 1996 • The Office of Inspector General (OIG) and the Department of Justice enforce federal, state, and local laws to control healthcare fraud and abuse • They conduct investigations and audits pertaining to the delivery of and payment for healthcare services.

8. Incorrect Coding • In egregious cases, a doctor can be fined, excluded from Medicare and Medicaid, lose their medical license, and even do jail time. • More commonly, the government imposes financial penalties.

9. Incorrect Coding • The civil monetary penalty for healthcare fraud has been increased from $2000 to $10,000 for each item or service for which fraudulent payment has been received. • The monetary assessment has been increased from not more than twice the amount to not more than three times the amount of the overpayment.

10. Incorrect Coding • Two practices have been added to the list of fraudulent activities for which civil monetary penalties may be assessed: 1. Engaging in a pattern of presenting claims based on a code that the person knows or should know will result in greater payments than appropriate. 2. Submitting a claim or claims that the person knows or should know is for a medical item or service that is not medically necessary.

11. Audits and Investigations What will trigger an audit or investigation? • A pattern of “upcoding” • Whistle blowers • E & M codes that are consistently different than average distributions for your specialty • Within a group setting, inconsistent coding among partners.

12. Audits and Investigations What will trigger an audit or investigation? • Excessive use of a code. • Coding level 5 services and not preventive medicine codes for annual physicals. • Use of symbols or shorthand • Lack of specificity about what you are reviewing. (Review of systems as unremarkable is insufficient) • Frequent coding based on “time”

13. New Pt Code Actual Medicare Difference 99201 5% 1.3% 3.7 points 99202 20% 15.9% 4.1 points 99203 60% 45.4% 14.6 points 99204 15% 30.5% -15.5 points 99205 0% 6.9% -6.9 points EstPt Code Actual Medicare Difference 99211 8.3% 3.7% 4.6 points 99212 8.3% 4.3% 4 points 99213 58.3% 48.2% 10.1 points 99214 16.7% 40.2% -23.5 points 99215 8.3% 3.6% 4.7 points

14. Procedural Coding • There is a code for every procedure that physicians perform • Each code dictates the price for that service that will be charged by the physician

15. Procedural Coding • Each code is a five-digit number, which identifies the procedure or service • Health care entities (hospitals, clinics, individual providers) attach a price to each code • Actual reimbursement will vary depending on what insurance companies or government payers will allow

16. Procedural Coding Organization of codes • Anesthesia 00100-01999; 99100-99140 • Surgery 10021-69990 • Radiology 70010-79999 • Pathology & Lab 80048-89356 • Medicine 90281-99199; 99500-99602

17. Procedural Coding Add-on codes • Additional procedures that are commonly done in addition to the primary procedure • Identified by terms like “each additional” • Performed by same physician • Cannot be reported separately

18. Procedural Coding Modifiers • Additional two-digit code that is added to the primary CPT code • Format: 11300-59 • Some modifiers are attached to E & M codes; others to procedural codes

19. Procedural Coding Modifiers • Both a professional and technical component • More than one physician and/or location • Only part of a service was performed • An adjunctive service was performed • A bilateral procedure was performed • Service or procedure performed more than once

20. Procedural Coding Global Procedure Codes • Most procedure codes are “global”, i.e. they include ALL care related to that particular procedure • May or may not include initial encounter • For example, fracture care includes initial evaluation, treatment (splint or cast), follow up, and treatment of complications, if done by same provider

21. E & M Coding • Evaluation and Management • Billing for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents: ❖ Patient type; ❖ Setting of service; and ❖ Level of E/M service performed.

22. E & M Coding • The “level” of the code is then determined by three components: • Patient History • Physical Exam • Medical Decision Making • For a new patient, all 3 components are used. The lowest “level” determines the code. • For established patients, only 2 out of 3 are needed.

23. E & M CodingPatient Type • For purposes of billing for E/M services, patients are identified as either new or established: • New patient -- has not received any professional services from the physician/non-physician practitioner (NPP) or another physician (of the same specialty) who belongs to the same group practice in the past three years. • Established patient -- has received professional services as noted above in the past three years.

24. E & M CodingPatient Type • “Any professional services” includes: • Emergency department visit • Treatment as an inpatient (including newborns) • Nursing home visit • Outpatient visit at any location

25. E & M CodingPatient Type • Example #1 • Joe comes in c/o cough. He has never been seen at FPC. • When reviewing his chart, you see that he had a knee replacement in 2012 at Allen. • Dr. Johnston was the attending physician. • Family Practice was consulted for medical management of his hypertension. • Is Joe a new or established patient for E & M Coding purposes?

26. E & M CodingPatient Type • Example #2 • Holly comes to the clinic for follow up of hypertension, diabetes and CHF. • She moved away in July 2011, but just moved back to Waterloo. • Her FPC chart contains a complete history, and her last office visit was 12/01/10. • You note that her medications were refilled by phone on 7/01/11. • Is Holly a new or established patient for E & M coding purposes?

27. E & M CodingPatient Type • Example #3 • While you are on team, you admit Alfred for CHF. Dr. Kettman is his PCP. • The following year, Alfred changes insurance carriers, and can no longer see Dr. Kettman. • He remembers the excellent care you gave him in the hospital, and comes to FPC to see you for his CHF. • Is Alfred a new or established patient for E & M coding purposes?

28. E & M CodingSetting of Service • E/M services are categorized into different settings depending on where the service is furnished. Examples of settings include: ❖ Office or other outpatient setting ❖ Hospital inpatient ❖ Emergency department ❖ Nursing facility ❖ Home

29. E & M CodingSetting of Service • In each setting, there different types of services which may be billed. • OFFICE • Office visit • Office consultation (new or est.) • Preventive medicine services • Nursing Facility • Initial nursing facility care (new or est.) • Subsequent nursing facility care • Nursing facility discharge

30. E & M CodingSetting of Service • Hospital • Initial hospital care (new or est.) • Subsequent hospital care • Observation (admit/discharge same day) • Hospital discharge • Inpatient consultation • Emergency Department • Emergency department visit (new or est.) • Physician direction of EMS care

31. E & M CodingSetting of Service • Critical Care • May be billed in hospital or ED setting • Critical care E/M (first 30-74 minutes) • Critical care (each additional 30 minutes) • Domiciliary or Rest Home Services • Home Services

32. E & M CodingSetting of Service • Prolonged Services • With direct patient contact • Without direct patient contact • Anticoagulant Management • Medical Team Conferences • Care Plan Oversight Serices • Home health agency • Hospice • Nursing facility

33. E & M CodingLevel of Service Provided • In general, the more complex the visit, the higher the level of code the physician or NPP may bill within the appropriate category. • In order to bill any code, the services furnished must meet the definition of the code. • It is the provider’s responsibility to ensure that the codes selected reflect the services furnished.

34. E & M CodingLevel of Service Provided • There are three key components when selecting the appropriate level of E/M service provided: • Patient History • Physical Examination • Medical Decision Making • The criteria for each component varies depending on the setting and type of service.

35. E & M CodingLevel of Service Provided • Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. • For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.

36. E & M CodingLevel of Service Provided

37. E & M CodingLevel of Service Provided

38. E & M CodingLevel of Service Provided Patient History Definitions • Problem Focused: CC, brief HPI • Expanded PF: CC, brief HPI, pertinent ROS • Detailed: CC, extended HPI, extended ROS, pertinent PMH, FH and/or SH • Comprehensive: CC, extended HPI, complete ROS, complete PMH, FH and SH

39. E & M CodingLevel of Service Provided Patient History Definitions • HPI Elements: (Brief 1-3; Extended 4+) • Location • Duration • Severity • Modifying factors • Context • Timing • Quality • Associated symptoms

40. E & M CodingLevel of Service Provided Patient History Definitions • ROS Definitions • Pertinent=1 • Extended 2-9 • Comprehensive 10+

41. E & M CodingLevel of Service Provided Organ Systems: • Constitutional • Eyes • ENT • Cardiovascular • Respiratory • GI • GU • Musculoskeletal • Hematologic/Lymphatic • Neurologic • Endocrine • Psychiatric • Skin • Allergic

42. E & M CodingLevel of Service Provided Physical Exam Definitions • Problem focused: limited exam of affected area • Expanded PF: limited exam of affected area and related systems • Detailed: extended exam of affected area and related systems • Comprehensive: general multisystem OR complete exam of affected system

43. E & M CodingLevel of Service Provided Physical Exam Definitions • Problem-focused: 1-5 elements in 1 or more organ systems/body areas • Expanded problem-focused: 6 or more elements in 1 or more organ systems • Detailed: at least 2 elements in at least 6 organ systems or body areas OR at least 12 elements in a single organ system • Comprehensive: All elements of at least 9 organ systems or body areas OR all elements of one single organ system

44. E & M CodingLevel of Service Provided Medical Decision Making • Number of possible diagnoses and/or management options • Amount or complexity of information • Risk of complications, morbidity, and/or mortality

45. E & M CodingLevel of Service Provided Medical Decision Making Number of possible diagnoses and/or management options • STRAIGHTFORWARD: One self-limited or minor problem • LOW COMPLEXITY: * One or two self-limited problem(s) or symptom(s) * One stable chronic illness * Acute self-limited uncomplicated illness or injury * Risk of complications, morbidity or mortality is low

46. E & M CodingLevel of Service Provided Medical Decision Making • MODERATE COMPLEXITY: * Three or more or self-limited problems * One or more chronic problems with mild to moderate exacerbation, progression or side effects * 2 OR 3 stable chronic illnesses * Undiagnosed new illness, injury or problem with uncertain prognosis * Acute illness with systemic symptoms * Risk of complications, morbidity or mortality is moderate.

47. E & M CodingLevel of Service Provided Medical Decision Making • HIGH COMPLEXITY: * One or more chronic illnesses with severe exacerbation, progression, side effects * Four or more stable chronic illnesses * Acute complicated injury with significant risk of morbidity or mortality * Acute or chronic illnesses that pose a threat to life or bodily function * Abrupt change in bodily function (e.g., seizure, CVA, acute mental status change) * Risk of complications, morbidity/mortality is high.