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

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

Credentials and Organizations 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.

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

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

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

2007 GI ICD-9-CM CODES 284.1 Pancytopenia 284.2 Myelophthisis 288.00 Neutropenia, unspecified 288.01 Congenital neutropenia 288.02 Cyclic neutropenia 288.03 Drug induced neutropenia 288.04 Neutropenia due to infection 288.09 Other neutropenia 528.00 Stomatitis and mucositis, unspecified

2007 GI ICD-9-CM CODES 528.01 Mucositis (ulcerative) due to antineoplastic therapy 528.02 Mucositis (ulcerative) due to other drugs 528.09 Other stomatitis and mucositis ulcerative) 538 Gastrointestinal mucositis (ulcerative) 780.96 Generalized pain 780.97 Altered mental status V18.51 Family history (of), Colonic polyps V18.59 Family history (of), Other digestive disorders

2007 GI ICD-9-CM CODES V45.86 Bariatric surgery status V82.71 Screening for genetic disease carrier status V82.79 Other genetic screening V85.51 Body Mass Index, pediatric, less than 5th percentile for age V85.52 BMI, pediatric, 5th percentile to less than 85th percentile for age V85.53 BMI, pediatric, 85th percentile to less than 95th percentile for age V85.54 BMI, pediatric, greater than or equal to 95th percentile for age

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

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.

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

New 2007 CPT Code 91111 Wireless capsule endoscopy, esophagus only

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

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

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

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

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

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

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)

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

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

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.

History History of Present Illness Past History Review of Systems Past Medical History Family History Social History Review of Systems

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

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

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

Physical Examination Requirements 1995 vs. 1997 Guidelines

Guidelines Level of Visit 1995 1997 Level 1 99201, 99241, 99251 1 organ system 1-5 bullets Level 2 99202, 99242, 99252 2-4 organ systems 6 bullets Level 3 99203, 99243, 99253, 99221, 99218 5-7 organ systems 12 bullets Level 4 or 5 99204-5, 99244-5, 99255-5, 99222-3, 99219-20 8-13 organ systems 2 bullets from 9 organ systems

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

Medical Decision Making The Key to Accurate Reimbursement

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

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

Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal 99201-99202, 99241-99242 99251-99252, 99281-99282 99271-99272, 99212  One self-limited or minor problem, eg. Cold, insect bite  laboratory tests  Chest x-rays, EKG/EEG, Urinalysis  Ultrasound  rest  gargles  elastic bandages  superficial dressings Low 99203, 99213, 99243, 99253 99283, 99273, 99213, 99221, 99218, 99231  two or more self limited or minor problems  one, stable chronic illness, eg, well controlled Crohn’s, Ulcerative colitis, GERD  Non Cardiovascular Imaging studies with contrast, eg, barium enema  OTC drugs  IV fluids without additives

Moderate 99204, 99214, 99244, 99254 99284, 99274, 99214, 99222, 99219, 99232  one or more chronic illnesses with mild progression, or side effects of treatment  two or more stable chronic illnesses  undiagnosed new problem with uncertain prognosis  acute illness eg,, colitis  diagnostic endoscopies with no identified risk factors  deep needle or incisional biopsy  obtain fluid from body cavity, eg, Paracentesis  prescription drug management  therapeutic nuclear medicine  IV fluids with additives High 99205, 99215, 99245, 99255 99285, 99275, 99215, 99223, 99220, 99233  one or more chronic illnesses with severe exacerbation, progression or side effects of treatment  acute or chronic illnesses or injuries that pose a threat to life or bodily function  diagnostic endoscopies with identified risk factors  parenteral controlled substances  drug therapy requiring intensive monitoring for toxicity  decision not to resuscitate because of poor prognosis