The Coding Primer

1. The Coding Primer “How to Code” basics for primary care providers. Updated for 2009

2. Coding: “Can’t Live With It. Can’t Live Without It.” • Coding is important because it builds the electronic health record. • It is the language we use to collect our fees. • It has become and will become even more the means by which we will be alotted cash and manpower.

3. How are we doing now? • 573 encounters audited by our coders in August 2007. • 84.05% Diagnosis correct. • 74.57 % Eval/management codes correct. • 67.18 % CPT codes correct. Document what you performed. Method / Location / Quantity / Size / Layers / Time frames. • 51 % of encounters had errors found!

4. In general… • Code only what you know. If the diagnosis is “likely” or rule-out code for the symptoms the patient is having. E.g. CHF rule out can be coded as lower leg swelling. • Don’t code for resolved conditions. Instead use the v67 series for follow up exams. • List complicating factors. Comorbidities, other chronic conditions the patient may have, adverse effects of medications that may be indicated. Helps to determine the complexity of the decision making process you are making.

5. In general… • Try to be clear about taking intermediate steps to address a patient’s condition. This can boost the complexity of the condition to the coder. Trying first physical therapy, nsaids prior to surgical consideration for example. • Use the “50%” button as the exception, not the rule.

6. In general… • Be specific about reviews of labs or xrays. Labs reviewed with patient showed elevated wbc indicating sepsis or inflammation. If a patient is following up blood pressure check tell what was wrong with the blood pressure to begin with. • Be sure to add the nurse, MA or corpstaff as an additional provider to help show clinic workload.

7. In general… • Medical necessity should drive ordering of labs or other diagnostic studies. Write a story that tells why these labs need to be done. The complexity of the office visit is based on the story not on the fact that so many labs were ordered. • When applicable, code “obesity” as it can help to increase the medical decision making score.

8. In general… • Collect credit for diagnostic decisions. If the provider went through the medical decision making process to determine a patient needed a certain test, even though the patient refused the test, the provider should receive credit for that process, provided the process is documented. E.g. colonoscopy screening / tobacco cessation counseling / obesity nutrition consults.

9. In general… • For residents…Give name of staff you discussed the case with. • Vital signs must be stated to have been reviewed. • EKG must be reviewed in your note to obtain credit for having done it (CPT 93000). • LOOK! At your clinic favorites for CPT codes and for Diagnoses!

10. Code for the -25 modifier. • When a procedure is done separate from the office visit diagnosis. When providing a specific treatment plan during a prev med visit. E.g. during a PAP smear patient brings up depression and you counsel and provide medical therapy. During an EST patient elects to start tobacco cessation and you perform counseling.

11. How to: Code for Preventive Med Visits • V20.2 visit for: Well baby, Well child • V72.31 Normal Pelvic Exam with Cervical PAP (Well Woman) • V76.2 Screening Pap • V70.0 Normal Routine History and Physical (Well Adult) • V70.3 School/Camp Physical • Disposition: Age-Appropriate Prev Med Code! E.g. 99395 RVU =1.36 (99213RVU= 0.67)

12. How to: Code for Routine OB Care • V22.0 Supervision of Normal First Pregnancy • V22.1 Supervision of Pregnancy • V22.2 Pregnancy incidental to condition. • CPT ! : NOB = 0500f, Antepartum = 0502f, Post-Partum Exam = 0503f • Disposition : 99499 99499 with 0500.0502,0503 = 0.83rvu ! 99213=0.67

13. How to: Code for Well Woman Visit • V72.31 Routine Physical Exam with a GYN component. When cervical PAP Smear is performed must add diagnosis V76.2 Screening PAP. • If s/p hysterectomy V72.31 still applies with V76.47 for vaginal PAP. • CPT/HCPCS!: “Q0091” Obtain PAP / Transport to Lab • 87210 wet prep/koh (done and interpreted in clinic) 82272 Hemoccult from DRE (done in clinic). • Q0091 RVU = 0.37 • Disposition: Use age-appropriate Prev Med Code!

14. How to: Code Tobacco Cessation • 305.1 Nicotine Dependence • New! CPT: in E&M section add “Additional E&M” code using -25 modifier. • 99406: 3-10 minutes of cessation counseling • 99407: > 10 minutes of cessation counseling • 96153: provider group visit • HCPCS S9453: non-provider cessation counseling • 99406 RVU = 0.24 • 99407 RVU = 0.50

15. How to: Code Obesity 278.00 Obesity (bmi 30-39) 278.01 Morbid Obesity (bmi>39) 278.02 Overweight (bmi 25-29) • V77.8 visit for: screening exam obesity

16. How to: Code for Skin Biopsies • Punch / Shave Biopsy of: • Macules and Papules 709.8 • Subcutaneous Nodule 782.2 • Acrochordon 701.9 • CPTBiopsy Skin:11100 • Each additional biopsy: 11101 • CPT Skin tag removal: 11200 (up to 15 lesions) • Each additional 10 biopsies: 11201 • CPT Destruction of benign lesion by cryotherapy: 17110: up to 14 lesions 17111: 15 or more lesions.

17. How To: Code for Exercise Stress Testing • Exercise Stress Test: 786.50 Chest pain or v81codes visit for: screening exam cardiovascular disorders (no hx recent chest pain) • CPT Cardiovascular Stress Test: 93015 • CPT Stress Test with Pharmacologic Challenge: 93015

18. How To: Code for Colposcopy • Colposcopy Diagnosis: 795. series Abnl PAP of Cervix • CPT Colposcopy without biopsy 57452 • CPT Colposcopy with biopsy of cervix and ECC 57454 • CPT Colposcopy with ECC only 57456 • CPT Colposcopy with biopsy only 57455

19. How To: Code for Vasectomy • Pre Vasectomy Counseling and Examination: v25.09 • Vasectomy Procedure: v25.2 Surgery of Male Genitalia Sterilization • CPT 55250 • Post-Vasectomy Follow-up: v67.00

20. How To: Code Chronic Kidney Disease • 585.9 Chronic Kidney Disease (NKF Classification) • 403.9 Hypertensive Chronic Kidney Disease

21. How To: Code Adverse Drug Reaction • E947.9 Adverse Effect of Drug Therapy • Enter Medication as “ADR” / list effect drug had on patient.

22. How To: Code for Diabetes • Diabetes 250.00 • Pre-Diabetes (Impaired Glucose Tolerance) 790.29 • Gestational Diabetes 648.80 • Visit for: Screening Exam Diabetes v77.1 • CPT: for Foot Exam • 2028F: for normal exam G0247: if neuropathy is diagnosed

23. How To: Code for Alcohol Use Counseling • 305.00 Alcohol abuse, unspecified (non-dependent) • 303.90 Alcoholism, unspecified (dependent)

24. How To: Code for Mammogram Review / Screening • Mammogram Screening: v76.12 • CPT: Review Mammogram Results 3014F

25. How To: Code for Osteoporosis Screening • Osteoporosis 733.00 • Visit for : screening exam osteoporosis v82.81 • Anticipatory Guidance: Osteoporosis v65.49

26. How To: Code for Colon Cancer Screening • Visit for: Screening neoplasm malignant colon. V76.51 • Heme Occult testing CPT: 82272 if interpretation is performed in the clinic • Flex Sig CPT:45330

27. How to: Code for Screening Exams • V76.51 screening colon cancer • V77.1 screening, diabetes • V76.9 screening cancer, unspecified • V77.91 screening lipid disorders • V81.0 screening cardiac disease • V82.9 screening, unspecified