Coding 101 Handouts for this presentation include: 1995 CMS coding guidelines; 1995 coding guidelines – edit by Dianne Demers; Audit cheat sheet; Evaluation and Management codes; Counseling codes Taken from “Beginning Coding”, “Intermediate Coding”, and “I Hate Coding” by Dianne Demers

Ice Breaker Group icebreaker activity – eg toilet paper exercise where each person takes any amount of toilet paper they want. Then explain to the group that they need to tell the group a fact about themselves for each square of TP they took. Or have them pick a number between 1 and 5. That number will be the number of things they need to tell the group about themselves.

Coding and Documentation 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 Content: Discuss why it is important to code and document correctly. Discuss components of coding compliance.

Coding Background and Terminology

Coding Definition Coding is an alphanumeric system used to translate medical procedures and services into data We all probably know this, but want to be sure we are all on the same page.

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) The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel[1]. The CPT code set accurately describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures between physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The current version is the CPT 2007. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR is a manual published by the American Psychiatric Association (APA) and includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of Diseases, commonly referred to as the ICD. Since early versions of the DSM did not correspond with ICD codes and updates of the publications for the ICD and the DSM are not simultaneous, some distinctions in the coding systems may still be present. For this reason, it is recommended that users of these manuals consult the appropriate reference when accessing diagnostic codes. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases. The International Classification of Diseases is published by the World Health Organization. The ICD is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is a core classification of the WHO Family of International Classifications (WHO-FIC). An important alternative to the mental disorders section of the ICD is the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the primary diagnostic system for psychiatric and psychological disorders within the United States and some other countries, and is used as an adjunct diagnostic system in other countries. Since the 1990s, the APA and WHO have worked to bring the DSM and the relevant sections of ICD into concordance, but some differences remain. The ICD is revised periodically and is currently in its tenth edition. The ICD-10, as it is therefore known, was developed in 1992 to track mortality statistics. ICD-11 is planned for 2011 and will be revised using Web 2.0 principles.[1] Annual minor updates and three yearly major updates are published by WHO. The ICD is part of a "family" of guides that can be used to complement each other, including also the International Classification of Functioning, Disability and Health which focuses on the domains of functioning (disability) associated with health conditions, from both medical and social perspectives.

Coding Is Not The Same As Billing This training will not teach you how to bill. It teaches you how to code to tell your story – what you did & why.

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

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. Some people believe that you can only code certain codes because you are a SBHC. This is not true.

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 Change your thinking about coding. Coding is used to tell your story. Many people think SBHCs do not do anything serious, but you do, so tell the story.

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)

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. Assumptions will be made by others about what you did by virtue of what you code. AAP reports each year that a majority of its members under code.

There Are Two Coding Guidelines - 1995 & 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 You chose the guidelines you use. The rules say you may choose which ever one is more advantageous to your agency. 1995 guidelines are 15 pages long. 1997 guidelines are 57 pages long. Unless your agency says to use 1997, suggest you use 1995 – you do the math. Also keep in mind that neither guidelines are pediatric based – they are Medicare.

Coding Guidelines 1995 vs. 1997 This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version. www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf 1995 and 1997 guidelines are available at http://www.cms.hhs.gov/MLNGeninfo/ see products catalog

Fraud Intentional deception or misrepresentation Deliberately billing for services not performed Unbundling of services Intentionally submitting duplicate claims Everyone is afraid of fraud. Keep in mind that fraud is intentional

Abuse Improper billing practices Billing for non-covered services Misusing codes on a claim form Does not apply to practitioner – billers only

Errors Accept it, you will make them. Your best defense is having a plan for your coding and being able to explain it. Don’t be afraid of an audit. Keep your guidelines in a nearby drawer so you can show why you coded as you did. Auditors will tell you if you made an error. Keep in mind that under coding is also an error and subject to the same fines as over coding.

Coding Does Not Equal Good Medicine =

But - Coding is Good Documentation

CPT Codes document: Level of Service Procedures Provided

Evaluation & Management Examples of CPT codes Preventive Health 99391 99392 99393 99394 99395 99397 Evaluation & Management 99211 99212 99213 99214 99215

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

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

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 4th or 5th digit will result in the denial of a claim. Do not add any additional digits, even zero

ICD-9-CM Codes Range from 001.0 to V82.9 They identify: Diagnoses Symptoms Conditions Problems Complaints Other reason for the procedure, service, or supply provided

ICD-9-CM Codes Three volumes Volume 1 Tabular List of Diseases Notes all exclusive terms and 5th-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)

“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

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

Rules for Coding Outpatient Visits

Determine Type of Office Visit Evaluation and Management New Patients vs. Established Patients Preventive Health Visits Counseling Visits Medical Visit – talker only Mental Health Visits There are 4 kinds of office visits. Mental Health is a different training.

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. In order to see one of these patients, you must have a medical necessity for seeing them. This it the overriding principle in coding. - There are certain things you normally do for a cut on a foot, and certain things you normally do for a sore throat. You cannot just write more for a cut foot to try a justify getting paid more.

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 Every patient must have a chief complaint. But keep in mind it is everything the patient tells you. Eg. I hurt my ankle, and oh yeah, I can’t breath. They came in for the hurt ankle, but CC is also the “can’t breath.”

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 Acute visits is a misnomer. They are Evaluation and Management visits. It is all a counting game – 5 of this, 7 of this, later is will be 3 of this and that.

Evaluation/Management (E / M) Services Beginning information about coding deals with the three key components: History Examination Medical Decision Making We talked about they type of patients and E/M is one of those types. Start with the key components. At this point you only need to count to three.

Evaluation/Management (E / M) Services There are 5 Levels of service Minimal Self-Limited or Minor Low Severity Moderate Severity High Severity Then look at levels of care possible. Only need to count to five. Words can be confusing as we all define “minimal” differently. Look how the levels are defined.

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 Remember level one was defined as “Minimal” But the words can be confusing and there are definitions of what a level on is so we recommend you use the term “Level One.” - By the way, this is the usually level used by an RN.

CPT Codes Used for E/M Visits New Patients Level 1 99201 Level 2 99202 Level 3 99203 Level 4 99204 Level 5 99205 Established Patients 99211 99212 99213 99214 99215 E/M codes available

Coding Steps Next we are going to discuss the coding steps and the rules that govern these rules. It may seem a bit confusing at first, but it is important that you understand the rules and then the explaination will follow

Coding Steps First Step - Determine if your patient is: A New Patient or An Established Patient First step – take out the coding audit cheat sheet – Handout 1 - look in the middle of this sheet and you notice that you have to choose type of visit and if patient it new or established

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 Very important to understand this For instance – most CHCs have Medical, dental and mental health. If pt was seen this year in mental health only, then they are new to medical health. SBHCs are part of medical, so if seen at the main center, they are an established patient to the SBHC. Check with billing to be sure. ER visits are always considered new.

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

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 This is the second step in coding. HPI = History of present Illness ROS = Review of symptoms PFSH = Personal, family and social history You will see all of these referenced in the middle and bottom of coding audit cheat sheet – Handout 1

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 Continue with the coding audit cheat sheet – Handout 1 . You will use this sheet to figure out the coding level. We will have examples later in the presentation of how to determine the level of service.

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, PFSH 4 Examination Medical Decision Making 3 This is the lowest level Continuing to refer to coding audit cheat sheet – Handout 1 : This is on the bottom half of the coding audit sheet. The level of visit for a new patient is the lowest of all three levels. If this is not clear, be patient. We will walk through this later. All we are talking about now is the numbers for the level of the visit. Coding for this new patient would be a 3 because that is the lowest level of these three components.

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 Still referring to the coding audit cheat sheet – Handout 1 .

Example – Established Patient HPI, ROS, PFSH 3 This is the middle level EXAM 2 Medical Decision Making 4 Continuing to refer to coding audit cheat sheet – Handout 1 . This example for an established Pt would be a level 3 because it is the middle level of the 3 components 3– 2 – 4. This is the advantage to knowing if your patient is established. If this same patient were a new patient, the coding level would be a 2. Why is this? Good question, but no good answer. There has to be a system, and this one is what AMA came up with. They have been talking about a revision, but it hasn’t been done yet.

Why is this?

Answer . . . There has to be a system, and this is what AMA came up with.

How to Steps of Coding

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) To determine the level of service, you need to determine the level of each of these components. This is still from the coding audit cheat sheet – Handout 1 - Look at the bottom area for listing the Medical Decision Making – see that it references to determine this first – coding audit cheat sheet page 2 – Handout 2

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 Medical Decision making - Look at coding audit cheat sheet page 2 – Handout 2 . Note there are 3 sections to Medical Decision Making. You must determine a level in each section.

Determine Level of Medical Decision Making Section I: Diagnosis or Management of Problems 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Continue with coding audit cheat sheet page 2 – Handout 2 - look at Section I on back of coding audit sheet – level 4 (99214) – second bolded item: “Acute illness with systemic symptoms” Let’s say a Child comes in with fever and says he feels ill = this is a child with an acute illness with systemic symptoms and has the potential of a level 4 exam. An asthmatic with wheezing – level 4 potential. How many of you bill asthmatics as a level 3 because you don’t spend that much time with the patient. Most asthmatics with symptoms will be a level 4. (hard to get have a level 5, but not impossible. Let’s say our patient is a level 4 for management of problem – section I. Now look at section II – diagnostic procedure.

Determine Level of Medical Decision Making Section II: Diagnostic Procedures 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Still referring to coding audit cheat sheet page 2 – Handout 2 . Note that only level 2 diagnostic procedures are bolded. The reason for this is because it is the highest level of procedures commonly done in a SBHC. At least, my SBHC does not do too many barium enemas. But remember, Medical Decision Making level is based on two out of the three sections – so in your head, you can ignore this section. Move onto section III.

Determine Level of Medical Decision Making Section III: Treatment or Management Options 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Still referring to coding audit cheat sheet page 2 – Handout 2 . Look at section III - See level 4 – 99214 – see bolded area “Prescription drug management.” This means: “Continue your albuterol” “take this amoxicillin” or even “finish the amoxicillin given to you by another provider.” It does not mean that you had to prescribe the medication, you only have to management it. Eg – the asthmatic who you told to take his albuterol is a level 4 management option. However, there is a caveat – you may not end up with a level 4 exam, but you need to recognize that you started out with a level 4 potential. The other component of the E/M visit also have an effect on the coding level.

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) Now back to front of coding audit cheat sheet - handout 1. The history component also has three sections.

Determine Level of History Component Section I: History of Present Illness Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms These are all the components included in the History of Present Illness section of the patient History (included in the 1995 Guidelines).

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 These are all the components included in the Review of Systems in the patient History. Note – eyes are separate from ears, nose, throat – per the 1995 guidelines.

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 These are the components of patient, family and social history. Note - if you ask about smoking or second hand smoke exposure, you have one item of PFSH. There is no requirement that you have an item for each of the three. Medication allergy is 1 item of PFSH. It is OK to reference the date of previous gathered info – but you much be specific about the date you are referencing – eg “see allergies noted on PE done 6/6/07.”

History Component Matrix (Number of components of each HPI, ROS & PFSH required for each level) New 99201 99202 99203 99204 99205 Established 99211 99212 99213 99214 99215 HPI 1 4 ROS 2 10 PFSH Referring still to coding audit cheat sheet - handout 1 - note level 4 bolded in orange on the slide. There are 4 HPI components required, 2 ROS components, and 1 PFSH component. You can see from this that it is not that hard to justify a level 4 exam. Eg – HPI - a child comes in and has been wheezing for the past two days, is worse in the evening and when running, some improvement with inhaler. ROS – Take vitals and review of respiratory system yields that child has had asthma diagnosis for 2 years. PFSH = Father smokes in the house.

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 Continuing with coding audit cheat sheet - handout 1 – determine the level of physical exam. You must compare this to chart notes. Note – again the eyes are a separate item.

Determine Level of Physical Examination: # of body systems required for each level New 99201 99202 99203 99204 99205 Established 99211 99212 99213 99214 99215 Exam 1 4 5 8 Note number of components of exam needed for each level. For a level 4 you only need to examine 5 body systems. Eg: 1. alert with no acute distress noted - and you have vital signs done (constitutional), 2. PERRL, conjunctiva non-injected (eyes), 3. TMs WNL, teeth present and in good repair, nasal septum midline, no discharge, no sinus tenderness, throat slightly pink (ear, nose, mouth, throat) 4. neck supple, no masses or nodes palpated, (lymphatic) 5. Lungs clear bilaterally (respiratory). Most everyone does this much of an exam when patient presents with symptoms of a cold. However, if all these items are not relevant to chief complaint, you don’t need to put to chart all of them.

Coding Matrix Example: New Patient Established Patient History 3 Exam 2 Medical Decision Making Level of Coding Look at established patient - If you code to a level 3 - You need 3 items of History, 2 systems of exam, and an acute, uncomplicated illness with OTC prescribed to reach a level 3 coding. If you are not doing this level frequently, you are telling your management that you are not needed. A school aide can put on a band aid. Child with a headache who has not been sick all winter, you give Tylenol = level 3 exam. Most people code this as a level 2. Remember – you are paid for you training and expertise, not the amount of time it takes you to treat. Don’t down grade what you do.

Coding Matrix Example: New Patient Established Patient History 4 Exam 2 Medical Decision Making Level of Coding Here is another example. This example makes it clear why it is so important to determine if patient is new or established. The same exam is a level 2 for a new patient and a level 4 for an established patient. This records accurately what you do. It may not make sense, that the same exam is such different levels of coding, but that’s the way it is.

Coding Exercise

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. Get out the blank chart note (or progress note) – coding handout 3, blank encounter form - coding handout 4 and blank coding audit cheat sheet – handout 1. Document the visit with this student from the narrative above.

Here is an example of a completed exam Here is an example of a completed exam. This is Coding Handout 5 – completed chart note for case 10 – Suzi Q.

This is handout #6 completed encounter form – case 10

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

See Handout #7 – Completed audit cheat sheet for case 10 while I continue with next slide

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

Handout #8 – back of completed Audit cheat sheet – case 10

Preventive Services

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. We think of a lot of what we do as preventive. This is the actual definition of preventive. - Think physical exam, not all the other stuff we do. This is a comprehensive history and exam

Preventive Services “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination. Eg – “well Child exam”

Preventive Service Codes Age New Established < 1 99381 99391 1-4 99382 99392 5-11 99383 99393 12-17 99384 99394 18-39 99385 99395 40-64 99387 99397 65+ -Note that codes are by age -insurance companies pay you by the age of your client for preventive exams -requirements are different by age of client (EPSDT guidelines) If you are one day off – eg if client is 18 years old today and you use the code for the 12 – 17 year old, you will not get paid.

Preventive Services Appropriate ICD-9 codes would be: V20.2 for a Routine Infant or Child Health Check V70.3 for a Sports Physical These are the ICD.9 codes you will use a lot in a SBHC

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 If you do not report these, the insurance company does not consider that you did them. Note that immunizations and administration of immunizations are coded separately and are in addition to the V20.2.

Common Pitfalls in Coding

ICD-9 CM (Clinical Modification) Coding Guidelines Order to list ICD-9 codes Coding Order is Important Acute Reason patient is being seen needs to be listed first. Co-morbid diagnosis affecting treatment of principal diagnosis are listed next. List all other documented conditions coexisting at the time of the visit that require or affect patient care, treatment or management. Chronic diseases may be listed as often as they are treated Insurance companies recognize two things – 1) the first CPT code you list and 2) the first ICD.9 code you list. Eg – a kid comes in with a cut and wheezing. If you code a level 4 exam, be sure that asthma is the first ICD.9 that you list. Always list acute condition first. It is the main reason for visit and is used to justify the level of visit coded to.

ICD-9-CM Coding Guidelines DO NOT CODE: Conditions previously treated that no longer exist. Conditions that do not affect treatment or management at the current visit. Rule-out, suspected, questionable or probable diagnoses. All of these things can be in your note, but do not code them on your encounter form. There is no ICD.9 code to “Rule Out” anything. You can use the symptom lists of V codes – eg code a cough vs R/O URI. You can use the V code for “worried well”. Eg – student comes in for a totally unfounded reason. You aks questions and cannot figure out what is wrong. Or, they come in and are worried they have something because their friend has something, but they have not sumptoms. You can also use V70.3 – for administrative purposes – eg – school want you to check the child. Remember, these codes were not created for pediatrics – so they do not always fit well. Just do the best you can Also remember, you can not use an ICD.9 code for Otitis Media if it is resolved. You must use the V code for follow up.

ICD-9-CM Coding Guidelines Review of Systems Documentation Cannot say “all other negative” Must list pertinent and negative findings Must have a way to determine which systems were reviewed A check list is acceptable

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

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

Acute Problems within a Comprehensive Physical When doing a preventive health visit (V20.2) and there is a separate health acute problem – you can list both the preventive health visit code (first) and the acute visit code (second) – BUT THERE MUST BE ICD-9 CODES THAT JUSTIFY BOTH (the billing department must add a modifier)

Be sure to know the Reason for the Visit Counseling Codes are not meant to be added to Preventive Health and Acute Visits

Late Effects of Burns Late effects means the burn has healed. There should not be dressing changes.

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

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

Be Specific with the codes you use

784.1 Throat Pain EXCLUDES: Dysphagia 787.2 Neck pain 723.1 Sore throat 462 Chronic 472.1 Be sure to read the book. You cannot use 784.1 when one of the other four would be a better explanation.

AGAIN - About 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 Just to reiterate

Poor example incorrect coding for documentation See Handouts of Completed Note Sample 10a (handout 9) & Encounter Form 10a (handout 10)

Same young lady we saw before, but charting is different Same young lady we saw before, but charting is different. You audit this record. What level does this documentation justify? Take about 1 – 2 minutes to decide.

Completed Encounter form - Handout 10

Analysis of incorrect coding for documentation Here is how we get level 2.

Coding Audit Cheat Sheet Top half of form PATIENT IDENTIFIER____10a CODING AUDIT CHEAT SHEET TYPE OF SERVICE PROVIDED: Preventive Health – New patient ______ Preventive Health – Established patient ______ Counseling Services– No Physical Complaint Is time recorded in chart? YES _____ NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit: where counseling determines time Is the total time of the visit recorded YES _____ NO _____ Is the time spent in counseling recorded YES _____ NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit – NEW PATIENT Evaluation / Management Visit – ESTABLISHED PATIENT CPT & ICD-9 CODES USED CPT CODES: 99203 ICDE-9 CODES: 625.3 DO THE CPT/ICD-9 CODES CORRELATE? YES __X___NO ______ Notes show that patient was seen for and E/M visit, was a new patient, CPT coded by NP was 99203 (but was not supported by documentation), However IDC.9 was correct and CPT code and ICD.9 were possible match – correlated.

Coding Audit Cheat Sheet Bottom Half of Form HISTORY AND EXAMINATION New 99201 99202 99203 99204 99205 Established 99211 99212 99213 99214 99215 HPI 0 1 1 4 4 ROS 0 0 1 2 10 PFSH 0 0 0 1 2 EXAM 0 1 4 5 8 CHART AUDIT LEVELS FOR E/M VISITS HPI, ROS, PFSH 3 NEW PATIENT LEVEL 2 Lowest level supports level EXAMINATION 2 ESTABLISHED PT LEVEL ____ 2 of 3 or middle level supports level MEDICAL DECISION MAKING 3 HPI, ROS, PFSH only has one component (can be level 2 or 3). Examination has only 1 component (level 2), and Medical Decision is a level 3. Since Suzi Q is new, this is a level 2 (the lowest number). If 3 more components of the exam were documented, it would be a level 3. (You probably did 3 systems, but did not document them) Look at back of sheet (p. 2) to see how Medical decision making is determined.

Medical Decision Making Section I: Diagnosis or Management of Problems 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Look at Section I on back of coding audit sheet Section I – level 3 (99203) – bolded items. Dysmenorrhea can be considered either of problems in level 3.

Medical Decision Making Section II: Diagnostic Procedures 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Refer to coding audit sheet – diagnostic procedures - remember that this section can usually be ignored bevause Decision Making level is based on two out of the three sections - in this instance it is ignored completely as we did not do any procedures. Other levels of Diagnostic procedures do not usually apply to SBHC, but you only need to have 2 of the 3 areas of medical decision making to agree.

Medical Decision Making Section III: Treatment or Management Options 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 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 Refer to coding audit sheet. See level 4 – 99214 – see bolded area “Prescription drug management.” What does this mean? “Continue your albuterol” “take amoxicillin” or even “finish the amoxicillin given to you by another provider.” It does not mean that you had to prescribe the medication, you only have to management it. Eg – the asthmatic who you told to take his albuterol is a level 4 management option. However, there is a caveat – you may not end up with a level 4 exam, but you need to recognize that you started out with a level 4 potential. The other component of the E/M visit also have an effect on the coding level.

Unfortunately – Because of this documentation/coding error - you will not get paid for this visit. This is why it is very important to verify that charting supports all levels of coding decision making.

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