B4: Crack the Code: Addressing Billing Code Issues Laura Brey, Training Director, NASBHC

2 Welcome and Expectations

3 Objectives The Participant will be able to –Define CPT, ICD 9, and DSM 4 Coding –Explain the reasons why appropriate coding and documentation is so important in SBHC settings. –Demonstrate correct use of CPT and ICD 9 codes –Explain the rational for conducting routine medical record review and coding compliance audits in SBHC settings

4 Coding Background and Terminology

5 Coding Definition Coding is an alphanumeric system used to translate medical procedures and services into data

6 Types of Coding Current Procedural Terminology (CPT) International Classification of Diseases (ICD-9 Clinical Modification - CM) Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)

7 Coding Is Not The Same As Billing

8 Coding is Medicare Drive Pediatrics was not considered in original coding guidelines, so some of the things we do in SBHCs may not fit well

9 SBHC Coding There is no difference between coding in a SBHC and any other setting – the coding assumptions are the same. You provide the same level of care regardless of the location.

10 Why Code Correctly? –Reimbursement depends on it. –Codes describe the services you provide –Codes justify these services –Services not documented “never happened” PS: Never code for the purpose of getting more money

11 The Coding Process has 2 Parts 1. “What you did” = CPT 2. “Why you did it” = ICD-9 or DSM-4 TR YOU MUST ALWAYS USE BOTH a what and a why (NO EXCEPTIONS)

12 When a provider is under- coding they tell the wrong story This wrong story is:  SBHC Providers are seeing very few patients with multiple problems.  SBHC Providers should see more patients since they are not seeing complicated patients.  The SBHC should decrease the number of physicians and add more mid-level providers.

13 There Are Two Coding Guidelines & 1997 Both 1995 and 1997 guidelines are approved for use by CMS Agencies may specify use of 1995 or 1997 guidelines 1997 guidelines are more specific than 1995 in the examination portion (they are more computer friendly) New guidelines have been proposed, but have not yet been accepted

14 Coding Guidelines 1995 vs This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version. s/1995dg.pdf

15 Fraud Intentional deception or misrepresentation –Deliberately billing for services not performed –Unbundling of services –Intentionally submitting duplicate claims

16 Abuse Improper billing practices –Billing for non-covered services –Misusing codes on a claim form

17 Errors Accept it, you will make them. Your best defense is having a plan for your coding and being able to explain it.

18 Over-coding and Under-coding CPT and ICD-9 codes must always relate The first ICD-9 code you use drives the relationship to the CPT code

19 Coding Does Not Equal Good Medicine

20 But - Coding is Good Documentation

21 CPT Codes document: Level of Service Procedures Provided

22 Examples of CPT codes Evaluation & Management Preventive Health

23 ICD-9 and DSM4 Codes document: The reason behind the visit (They must support the CPT codes)

24 General Coding Principles Coding gets you paid for your services Coding can be used to justify the need for services to your funders

25 Coding with ICD-9 ICD-9 codes have 3, 4 or 5 digits –The greater the number of digits, the higher the specificity Use a 5-digit code when it exists Use a 4-digit code only if there is no 5- digit code with the same category Use a 3-digit code only if there is no 4- digit code within the same category PS: Omitting the required 4 th or 5 th digit will result in the denial of a claim. Do not add any additional digits, even zero

26 ICD-9-CM Codes Range from to V82.9 They identify: –Diagnoses –Symptoms –Conditions –Problems –Complaints –Other reason for the procedure, service, or supply provided

27 ICD-9-CM Codes Three volumes –Volume 1 Tabular List of Diseases Notes all exclusive terms and 5 th -digit instructions –Volume 2 Alphabetic Index of Diseases Does not contain detail – Do Not code from this volume –Volume 3 Procedures Used almost exclusively for hospital services PS: (All 3 Volumes are generally found in one binding)

28 “V” Codes For circumstances other than disease or injury Three categories: –Problem – Could affect overall health status, but is not a current illness or injury Ex.: V14.2 Personal history of allergy to sulfonamines –Service – Circumstances other than illness or injury Ex.: V68.1 Issue of a repeat prescription –Factual – Certain facts that do not fall into the “problem” or “service” categories

29 “V” Codes Can be used as a: –Solo Code –Principal code –Secondary code May represent check-ups, screenings, administrative requests, prescription refills

30 Rules for Coding Outpatient Visits

31 Determine Type of Office Visit Evaluation and Management New Patients vs. Established Patients Preventive Health Visits New Patients vs. Established Patients Counseling Visits Medical Visit – talker only Mental Health Visits New Patients vs. Established Patients

32 Determine Medical Necessity Services are reasonable and necessary for the diagnosis and treatment of illness or injury. All payors define necessity differently Clinical rationale must be documented through coding. You cannot write more, to get paid more.

33 Determine Chief Complaint The reason for the patient’s visit –S of a SOAP note Codes used must relate to chief complaint or they are invalid And, the chief complaint must be documented in the chart

34 Evaluation/Management (E / M) Services Used for acute care visits Five levels of service Seven components within the levels –Key components – history, exam and medical decision making –Contributory components – counseling, coordination of care, nature of presenting problem, and time

35 Evaluation/Management (E / M) Services Beginning information about coding deals with the three key components: –History –Examination –Medical Decision Making

36 Evaluation/Management (E / M) Services There are 5 Levels of service 1.Minimal 2.Self-Limited or Minor 3.Low Severity 4.Moderate Severity 5.High Severity

37 Most Problems Are Not Level 1 Level 1 is: –“A problem that may not require the presence of the physician, but service is provided under the physician’s supervision.” –This is a non-provider visit –Documentation is required – but flow sheet is sufficient –If this level is used, it states that the expertise of a medical provider is not necessary

38 CPT Codes Used for E/M Visits New Patients Level Level Level Level Level Established Patients

39 Coding Steps

40 Coding Steps First Step - Determine if your patient is: A New Patient or An Established Patient

41 Definition of a new patient: It is the patient’s first visit to the provider The patient has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years. PS: Any time a patient is seen in an Emergency Room they are considered a new patient

42 If your patient does not meet the definition of a New Patient, then they are an Established Patient

43 Coding Steps Second Step - determine the level of service for the visit, To do this you need to determine the level of service for each key component separately There are 3 key components They are: 1. History (HPI, ROS, PFSH) 2. Examination 3. Medical Decision Making

44 Coding Steps New Patients Within the 3 key components, there are 5 levels of service Remember to Consider the Key Components separately: –HPI, ROS, PFSH –Examination –Medical Decision Making

45 Example - New Patient The Level of Service for a new patient visit is determined by the lowest level of service (1 through 5) of the three key components HPI, ROS, PFSH4 Examination4 Medical Decision Making 3 This is the lowest level

46 Coding Steps Established Patients Again Consider the Key Components Separately: –HPI, ROS, PFSH –Examination –Medical Decision Making The level of service (1 – 5) is determined by the level that appears in 2 of the three components, or by the middle level

47 Example – Established Patient HPI, ROS, PFSH 3 This is the middle level EXAM2 Medical Decision Making4

48 How to Steps of Coding: Determine Level of Medical Decision Making Determine Level of History Component Determine Level of Physical Examination (You will need to reference the chart – examination notes for this)

49 Determine Level of Medical Decision Making Medical Decision Making consists of three sections: –Diagnosis or Management Problems –Diagnostic Procedures –Treatment of Management Options Level is determined by the level found in two of the three categories – or the middle number if all three are different

50 Determine Level of Medical Decision Making Section I: Diagnosis or Management of Problems One self- limited or minor problem Two or more self- limited or minor problems One stable chronic condition Acute uncomplicated illness One or more chronic illnesses with complications Two or more stable chronic conditions Undiagnosed new problem w/uncertain prognoses Acute illness with systemic symptoms Acute complicated injury One or more chronic illness with severe complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status

51 Determine Level of Medical Decision Making Section II: Diagnostic Procedures Lab X-ray EKG UA Ultrasound, etc. Venipuncture KOH Physiologic tests not under stress Pulmonary Function Barium Enema Arterial puncture Skin biopsies Physiologic tests under stress- cardiac stress tests Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography

52 Determine Level of Medical Decision Making Section III: Treatment or Management Options Rest Gargles Elastic bandages Dressings OTCs Minor surgery PT OT IVs without additives Minor surgery with risk factors Elective major surgery— no risk factors Prescription drug management IV fluids with additives Closed facture or dislocation treatment w/o manipulation Therapeutic nuclear medicine Elective Surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decision not to resuscitate or de- escalate care because of poor prognosis

53 How to Steps of Coding: Determine Level of History Component History component consists of three sections: –History of Present Illness (HPI) –Review of Systems (ROS) –Patient, Family, and Social History (PFSH)

54 Determine Level of History Component Section I: History of Present Illness Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

55 Determine Level of History Component Section II: Review of Systems Constitutional symptoms (fever, wt loss, etc.) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurologic Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic

56 Determine Level of History Component Section III: Patient, Family and Social History Past medical history –Medication allergies Patient’s family history Patient’s social history –Age-appropriate review of past and current activities Tobacco usage

57 History Component Matrix (Number of components of each HPI, ROS & PFSH required for each level) New Established HPI01144 ROS PFSH00012

58 How to of Coding Steps: Determine Level of Physical Examination Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskletal Skin Neurologic Psychiatric Hematologic/Lympatic/Immunologic

59 Determine Level of Physical Examination: # of body systems required for each level New Established Exam

60 Coding Matrix Example: New PatientEstablished Patient History33 Exam22 Medical Decision Making 33 Level of Coding23

61 Coding Matrix Example: New PatientEstablished Patient History44 Exam22 Medical Decision Making 44 Level of Coding24

62 Coding Exercise

63 Coding Exercise for Evaluation/ Management Services Suzy Q is a 16 y/o female with c/o severe “female” cramps - worse than usual. She states she took Midol and it only helped a little. She is a new patient. Document on the exam and encounter form to a level 3, using audit sheet as reference.

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66 How to Verify this is correct level of documentation to support level 3

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68 Count the components HRI 1 - Midol ROS 1 - cramps PFSH - 0 ___________ Level 3 Exam 1-const 2-Abd 2-Abd 3-back 3-back 4-genito 4-genito____________ Level 3 Med Decision - acute/uncomp - OTCs ___________ Level 3

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70 Counseling /Education Only During and E and M Visit

71 CPT Codes Used for Counseling/Education Only E and M Visits New Patients 10 minutes minutes minutes minutes minutes Established Patients 5 minutes minutes minutes minutes minutes 99215

72 Preventive Services

73 Preventive Services These visits include a comprehensive history and examination, as well as appropriate counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of age-appropriate laboratory/diagnostic procedures.

74 Preventive Services “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination.

75 Preventive Service Codes AgeNewEstablished <

76 Preventive Services Appropriate ICD-9 codes would be: V20.2 for a Routine Infant or Child Health Check V70.3 for a Sports Physical

77 Preventive Services Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately: –Examples: Snellen Test Laboratory Immunizations Administration of Immunizations

Coverage Issues A provider should know what services are covered. Services must be documented and medically necessary in order for payment to be made. Do you, as a provider, know if all services provided are covered? Are you documenting properly, and what about this “medically necessary” bit?

How Much are you Paid? Reimbursement –Reductions in reimbursement rates by provider type Physician- not discounted NP or PA - sometimes discounted Clinical Psychologist- discounted LCSW- further discounted Other- discounted if covered

Reimbursement Issues E&M codes are limited to physicians, PAs, NPs, nurses Same is true for 90805, 90807, codes An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs

Documentation and Coding: Fraud and Abuse Services MUST be medically necessary (determined by payers based on a review of services billed) Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities. Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider

Elements of “Incident To” An integral part of the physician’s professional service Commonly rendered without charge or generally not itemized separately in the physician’s bill Of a type that are commonly furnished in physician’s office or clinic Furnished under the physician’s direct personal supervision

83 Common Pitfalls in Coding

84 About Time With the Patient Do not base your level of service on time spent with patient. Time only comes into play if you are billing for counseling within an acute visit or if all you are doing is counseling

85 Sports Physicals They are not meant to be comprehensive physicals – their focus is different Check for an appropriate form You can bill for a complete PE and a sports PE within the same year

86 Counseling Visits Counseling visits are when client comes in to discuss a problem only. No hands are laid on the patient.

87 Example Dietary Surveillance & Counseling There must be a dietary problem in order to justify this code.

88 Be Specific with the codes you use

89 Coding Compliance Audit

90 Questions & Answers