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

2. Presenter: Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS
204 E Locust St
Lenzburg, IL 62255
Fax: (618)

3. 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.

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

5. 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 but in order to be paid requires a 5th digit indicator as to the quadrant involved is abdominal pain, epigastric area

6. 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

7. 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

8. 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

9. 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

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

11. 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.

12. 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:

13. New 2007 CPT Code
91111 Wireless capsule endoscopy, esophagus only

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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.

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

25. 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

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

27. 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

28. Physical Examination Requirements
1995 vs Guidelines

29. Guidelines Level of Visit 1995 1997 Level 1 99201, 99241, 99251
1 organ system
1-5 bullets
Level , 99242, 99252
2-4 organ systems
6 bullets
Level , 99243, 99253, 99221, 99218
5-7 organ systems
12 bullets
Level 4 or , , , ,
8-13 organ systems
2 bullets from 9 organ systems

30. 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

31. Medical Decision Making
The Key to Accurate Reimbursement

32. 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

33. 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

34. Level of Risk
Presenting Problem(s)
Diagnostic
Procedure(s)
Ordered
Management
Options
Selected
Minimal , , ,
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

35. 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