Basic Coding & Documentation

Basic Coding & Documentation
Daniel Stulberg, MD Dept. of Family & Community Medicine University of New Mexico Adapted by Daniel Stulberg from Thomas J. Weida, M.D. 9/18/2018

Adapted by Daniel Stulberg from Thomas J. Weida, M.D.
Goals & Objectives How to appropriately bill and code for levels of the visit. What needs to be included in the chart to back up the billing/coding. What NOT to do! 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Disclosures No known conflicts of interest Not a certified coder I code as part of my work A few slides used from Thomas Weida, MD – STFM 2012 FP Management Jo Ann Martinez CPC UNM Compliance Educator 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

What is Coding & Documentation & Why is it Important?
Your patient’s time and care is important Document what you did for patient care Your time and work is valuable Document what you did for your billing Record of pt illness for reference, legal, and compensation 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Billing Levels Established Patients
99211 Minimal 99212 Problem Focused 99213 Expanded 99214 Detailed 99215 Comprehensive 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Examples 99211 Minimal Nurse visit 99212 Problem Focused Brief follow up 99213 Expanded Routine visits 99214 Detailed Complicated visits 99215 Comprehensive Complete eval In General More Details Later 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Philosophy and Ethical Practice
Billing is based on what patient needs for their care The medical decision making drives the billing level What not to do Don’t charge level 5 for a cold! Can’t charge comprehensive for a cold. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Go for the Easy Stuff! Time Based 3 or More Chronic Problems 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Time Based Billing Practicing Clinician Amount of Face to Face Time “Greater than 50% in counseling/coordination” minutes minutes minutes minutes minutes Also the estimated time for E&M Once you are licensed 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

3 or More Chronic Problems
99214 Getting all the 99214’s You Deserve Addressing/Managing 3 Chronic problems Enough Hx Enough Complexity 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Billing for Tobacco Cessation Counseling – CPT codes
Capture the Coding, Outpatient Billing for Tobacco Cessation Counseling – CPT codes Smoke/Tobacco Counseling >3-10 min Smoke/Tobacco Counseling > 10 min 8 visits annually allowed in 12 mo period (4 sessions per attempt) Separate E/M service on same day, use modifier -25 Recently, Medicare has recognized counseling for tobacco cessation as an accepted treatment for conditions caused by tobacco use. The new codes are for smoke/tobacco counseling which lasts from 3-10 minutes and for counseling lasting greater than 10 minutes. If the counseling is done during a regular visit, the -25 modifier is added to the E&M code (for example, , and 99406). 8 counseling sessions are allowed in a 12 month period of time, 4 sessions per attempt. Counseling less than 3 minutes is considered part of a regular evaluation and management visit. Private insurers may not pay for this code. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D. Thomas Weida, M.D., PennState College of Medicine

Advanced Care Planning Discussions
Medicare 2016 Inpt or Outpt 99497 – first 30 minutes Face-to-face time w pt, family if pt unable Discussion Completion of forms 99498 Each additional 30 minutes FAQ’s 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Now For Something Different 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Diagnosis Codes ICD-10 International Classification of Diseases SNOMED Systematized Nomenclature of Medicine Can look up in Powerchart Dx list, or coding book or online 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Diagnosis Tips ICD-10 Right Left or Bilateral Acute/chronic/recurrent Primary/secondary Rank them by importance 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Clinical Documentation Improvement
Clinical note should describe the patient’s problems, severity of disease, complications and plan of care Problem list should be the table of contents for the patient’s record A good note should meet these goals and also will be sufficient for coding ICD 10, quality measures and profiles, and other compliance and regulatory needs 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

ICD-10 Cheat Sheats 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

ICD-10 Apps or EHR’s 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Now Things Get A Bit Complicated
Did you ever wonder what a Woods lamp is useful for? 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

What needs to be included in the chart to back up the billing/coding?
Good patient care Reference for coding audits Good structure, method of thinking 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Main Components History Physical Exam Medical Decision Making 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Main Components History Chief complaint HPI pertinent - at least 4 modifying factors for level 4 Location, quality, severity, timing, duration, modifying factors, context, associated signs/sx… PFSH – pertinent at least 1 for level 4 Review of systems – pertinent, at least 2 for level 4, 10 for the gold The numbers will make more sense later 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Unable to obtain List what List why Unconscious Adopted 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Main Components Physical exam Level 3 – at least two systems 4 Vitals count as one system Only need one more Level 4 – at least five systems Level 5 – at least eight systems 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Main Components -Medical Decision Making
Most complexmost complex 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Medical Decision Making
Number of problems addressed Length of differential diagnosis Complexity or risk Data reviewed, requesting old records, reviewing records, reviewing labs, reviewing previous studies, reviewing images, ordering labs, ordering tests 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

New Patients vs. Established
Never seen in this practice Never seen in this specialty Not seen in > three years Paid for extra work to practice Paid for extra work in getting more information 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Billing Levels New Patients
99201 Minimal 99202 Problem Focused 99203 Expanded 99204 Detailed 99205 Comprehensive 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Hitting on All Three Cylinders
New patients 3/3 History Physical examination Medical Decision Making Established patients 2/3 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Easy Pickings 99213 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Preventative Care Age New Patient Established Patient Under 1 year old
99381 99391 1-4 years old 99382 99392 5-11 years old 99383 99393 12-17 years old 99384 99394 18-39 years old 99385 99395 40-64 years old 99386 99396 65+ 99387 99397 Courtesy JoAnn Martinez UNM Compliance Educator

Preventative Care Diagnosis Codes
Preventative Diagnosis Code V20.31-V used for a child under 29 days old V20.2 – used for a patient from over 29 days old to 17 years of age V70.0 – used for a patient over the age of 18 Billable Diagnosis Codes “V” codes Signs and symptoms Code to the highest specificity Courtesy JoAnn Martinez UNM Compliance Educator

Procedures Tips Specify body area Specify if bilateral – modifier 50 Wounds and Excisions – length, size Complex wound closure – multilayer Biggest procedure first Global fees and follow-up visits 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Modifiers 25 – 2 or more separately identifiable services E&M plus procedure Wellness plus a separate significant problem Insurance / intermediary may not cover? Copay? Be clear in documentation 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Review of Systems Constitutional Cardiovascular Genitourinary Neurological Hematological/lymphatic Eyes Respiratory Musculoskeletal Psychiatric Allergic/immunologic Ears, nose, mouth, throat Gastrointestinal Integumentary - skin/breast Endocrine 10 is the magic number for 99215 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Review of Systems Non-Contributory for… Positive for… Review of Systems “otherwise 10 point ROS was negative” When it’s a jar 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Pre – Printed Forms History “Instant medical history” New Patient Forms Combined History and PE forms Check lists for ROS, PE 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

What Not To Do Don’t bill based on what you did vs what pt needed Don’t rely on other’s CC or HPI, can rely on forms or staff for PFSH and ROS Document work you didn’t do – IE templates Alarming rise in hermaphrodites! 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Supplies HCPCS - Healthcare Common Procedure Coding System List supplies used Checkbox or billing staff complete Facility fees 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Inpatient Services 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Inpatient Services Admissions - 3 levels Follow-up visits - 3 levels Observation status Discharge < 30 min. > 30 min. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Initial Hospital Care – New or Established: 3 Key Components
Capture the Coding, Inpatient Initial Hospital Care – New or Established: 3 Key Components 99221: Ave 30 min bedside or floor Decision making – low complexity Detailed history, detailed physical 99222: Ave 50 min bedside or floor Decision making moderate complexity Comprehensive history, comprehensive physical 99223: Ave 70 min bedside or floor Decision making of high complexity The rest of this presentation involves proper coding for inpatient visits. In my experience, physicians typically over-code hospital visits when the patient is improving, and under-code when patients have complicating factors. For admission history and physicals, the codes are the same for established or new patients. There are three levels based on decision making of low, moderate and high complexity. A has decision making of low complexity and a detailed history and physical. Typically, the physician spends 30 minutes at the bedside or floor for this admission. A involves medical decision making of moderate complexity and a comprehensive history and physical. Typically 50 minutes is spent at bedside or floor. Finally, a has medical decision making of high complexity and a comprehensive history and physical. Time is typically 70 minutes. So for admissions, there’s small, medium and large. Also, when documenting a note for inpatient care, remember to document all pertinent diagnosis's. Also, the documentation needs to be diagnosis's and not symptoms. For example, writing a down arrow and a K will not add to the complexity. This is not considered a diagnosis. Writing hypokalemia is a diagnosis, and will add to the complexity. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

Subsequent Hospital Care
Capture the Coding, Inpatient Subsequent Hospital Care 99231: Patient is stable, recovering or improving. Average of 15 minutes. 2 of 3 Key Components Decision making: Low Complexity Problem focused interval history Problem focused physical Subsequent hospital care also has 3 levels. For the patient is stable, recovering or improving. Decision making is of low complexity. The history is a problem focused interval history and the physical is a problem focused physical. You only need 2 of these three components to qualify: medical decision making, history, and physical. Typically 15 minutes is spent at bedside and on the patient’s hospital floor or unit. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

Capture the Coding, Inpatient Subsequent Hospital Care 99232 – Patient is not responding to treatment or has developed a minor complication. Average of 25 minutes. 2 of 3 Key Components Decision making: Moderate Complexity Expanded problem focused interval history Expanded problem focused physical For a 99232, the patient is responding inadequately to therapy or has developed a minor complication. Two of the three following key components must be met: medical decision making of moderate complexity, an expanded problem focused interval history, and an expanded problem focused interval physical. Average time spent at bedside, on unit or floor is 25 minutes. And remember, just like in the history and physical, complications must be diagnosis’s, not symptoms, and it must be in your note. Just because the Chest X-ray says right lower lobe air space disease, it won’t be considered a diagnosis until you record pneumonia in your note. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

Capture the Coding, Inpatient Subsequent Hospital Care 99233 – Patient is unstable or has developed a significant complication or a significant new problem. Average of 35 minutes. 2 of 3 Key Components Decision making: High Complexity Detailed interval history Detailed physical The highest level is The patient is unstable or has developed a significant complication or a significant new problem. Two of the three following key components must be met: medical decision making of high complexity, a detailed interval history, and a detailed interval physical. Average time spent at bedside, on unit or floor is 35 minutes. So briefly, the patient is stable, 99232, the patient is a little worse or not improving, and the patient is a lot worse or has a new problem. 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D. Thomas J. Weida, M.D. PennState College of Medicine

Prolonged Physician Service with Direct Patient Contact, Inpatient
Does not have to be continuous time On unit Use with E&M code which has avg. time listed < 30 min: NO Code 30-74 min: X 1 min: X 1 and 99357 >105 min: X 1 and X 2 or more for each additional 30 min (must be greater than 15 min additional for each use of 99357) 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Discharge Day of Service
Discharge – Time of patient care and coordination of care < 30 min > 30 min 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Initial Observation Care: New or Established, 3/3 Key Components
99218 Low Complexity Decision Making Detailed History, Detailed Exam 99219 Moderate Complexity Decision Making Comprehensive History, Comprehensive Exam 99220 High Complexity Decision Making 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Observation or Inpatient Admission & Discharge Same Day 3/3 Key Components 99234 Low Complexity Decision Making Detailed History, Detailed Exam 99235 Moderate Complexity Decision Making Comprehensive History, Comprehensive Exam 99236 High Complexity Decision Making 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Subsequent Observation Care 2/3 Key Components
99224 – Stable, Recovering, Improving. 15 min Low Complexity Decision Making Problem focused interval history Problem focused exam 99225 – Not responding or new minor problem. 25 min Moderate Complexity Decision Making Expanded problem focused interval history Expanded problem focused exam 99226 – Unstable or significant new problem. 35 min High Complexity Decision Making Detailed interval history Detailed exam 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Observation Care Discharge Services
Discharge on separate day than admission to observation status 99217 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Initial Inpatient Evaluation
Level HPI ROS FH/ SH EXAM A/P 99221 4 2-9 1-3 2-7 Simple 99222 10 >3 8 Moderate 99223 High Used by Permission from Mark Drexler

Subsequent Inpatient Evaluation
Level HPI ROS FH / SH EXAM A/P 99231 1-3 1 Simple 99232 2-7 Moderate 99233 4 2-9 High Used by Permission from Mark Drexler

Concurrent Care Multiple services, including the primary service and any sub specialists, providing care for a patient. Each service must document and bill only for the condition they are treating. On the day of initial consultation, the primary service may bill for the condition pertinent to the consultation. On days subsequent to the initial consultation, the primary service is unlikely to capture charges related to the condition being treated by any sub specialists. Used by Permission from Mark Drexler

Day of Discharge Reflects time spent coordinating care:
99238: <30 minutes 99239: >30 minutes Time does not have to be consecutive, face-to-face with the patient. Time spent on discharge coordination by house staff may not be billed by the faculty physician. Used by Permission from Mark Drexler

Time Based Billing Billing for time spent with patients on education/ counseling uses the following guidelines: 99231 – 15 minutes 99232 – 25 minutes 99233 – 35 minutes Documentation must support both the time spent and a summary of the discussion. Used by Permission from Mark Drexler

OB (L&D) Billing Visits
59400: Provide Prenatal Care and delivery via Vaginal (non operative or operative) 59409: Vaginal (non operative or operative) without prenatal care 59510: Provide Prenatal Care and delivery via Cesarean 59514: Delivery by cesarean without prenatal care *** Prenatal care provided but delivery done by OB (c-section) – no billing Used by Permission from Mark Drexler

Newborn Billing Visits
3 Levels: Initial Normal Newborn – billed by 1st provider to see newborn Subsequent Normal Newborn – billed by providers on each day after that (including discharge date) Same Day Normal Newborn Admission and Discharge – not done very often Used by Permission from Mark Drexler

Newborn Coding: Initial Care
Evaluation and management services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include: 99460: Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infants. 99461: Initial care, per day, for evaluation and managmeent of normal newborn infant seen in other than hospital or birthing center. 99463: Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date. Used by Permission from Mark Drexler

Newborn Coding: Subsequent Care
99462: Subsequent hospital care for the normal newborn is reported once per day. 99238 or 99239: Discharge services provided on a date subsequent to admission. Used by Permission from Mark Drexler

Wrap Up Goals and Objective How to appropriately bill and code for levels of the visit. What needs to be included in the chart to back up the billing/coding. What NOT to do! “Two out of three ain’t bad” 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

Getting all the 99214’s You Deserve 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

References and Resources
FP Management monthly coding tips and queries Powerchart Problem List for ICD-9 and SNOMED UNMG Compliance Coordinator - Glenda Harris 815 Vassar NE / MSC Albuquerque, NM 87131 Phone Fax 9/18/2018 Adapted by Daniel Stulberg from Thomas J. Weida, M.D.

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