1. Developmental Screening: Billing and Coding Michelle M. Macias, MD D-PIP Training Workshop June 16, 2006 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

2. Importance of Accurate Coding u Improved Information Processing –Accurate diagnostic coding requires analyzing all provided information (subjective and objective) u Decreased Liability –Documentation F Medico-legal –Compliance u Increased Reimbursement –One minute of extra work can result in an increased code level

3. Diagnostic Codes u International Classification of Diseases-Tenth Revision, Clinical Modification (ICD-10-CM) –Arranges diseases and injuries into groups according to established criteria –Numeric –Revised ~ q 10 years by WHO, annual updates by Health Care Financing Administration (HCFA) –U.S. still using ICD-9 codes, gradually implementing ICD-10

4. ICD-9 Codes u Code to the highest degree of specificity u Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results u Probable, suspected, questionable, or rule out should not be coded u List the ICD-9/10 code that is identified as the main reason for the service first, then list co-existing conditions u Chronic disease treated on an ongoing basis may be coded u Do not code for conditions previously tx that no longer exist

5. Developmental Coding: Examples u 783.42 Delayed milestones u 728.85 Hypertonia u 315.31 Language disorder, developmental u 315.9 Learning disorder, NOS u 348.3 Static encephalopathy

6. Current Procedural Terminology (CPT) u Published by the AMA u Listing of the codes and descriptions for procedures, services and supplies u Used to bill insurance carriers

7. CPT Coding 5 Basic Principles of Use u Practitioner should select diagnosis and procedure codes u Document patient’s services to support codes (compliance) u Use separate codes for different encounters u Learn to use modifiers, testing and add-on codes u Design a superbill/computerized routing sheet

8. “RVU Review” u Resource Based Relative Value Scale (RBRVS) u Relative Value Units (RVUs): “The Coin of the Realm” u A numerical value (relative reimbursement) assigned to a CPT code u Calculated on –Amount of physician work –Practice expenses –Malpractice cost –Service location (office vs. hospital)

9. RVU Components of Physician Work u Pre-, intra-, post- service work –Time to perform the service –Technical skill and physical effort –Mental skill and judgment –Psychological stress associated with iatrogenic risk

10. RVUs  Cash u RVUs are assigned by the Relative Value Scale Update Committee (RUC) u Each 3 rd party payer that uses RVus in payment calculations applies its own ‘conversion factor’ (CF) u The CF is multiplied by the RVU to determine that payor’s payment

11. TABLE 2 CPT Codes for Developmental Screening

12. Developmental Screening u 96110: Developmental screening –Limited developmental testing, with interpretation and report –Expectation is that the screening tool will be completed by a non-physician staff member and reviewed by the physician –No physician work is included in the RVU –Reported in addition to E/M services provided on same date, with modifier (-25) –Report for each screen administered –Medicaid may not pay separately for developmental screening when provided as part of Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT)

13. Developmental Testing u 96111: Extended developmental testing/evaluation –Used for extended developmental testing typically provided by the medical provider –Includes the interpretation and report –Based on 1 hr of physician work –Reported in addition to E/M services provided on same date, with modifier

14. Evaluation and Management (E/M) Codes u Bill based on level of complexity- 3 major components –History –Physical Exam –Medical Decision Making (MDM) u Bill based on time –Only if counseling and coordination of care > 50% of visit

15. “Complexity” Billing: History TypeHPIROSPFSH Problem Focused Brief (1-3) N/AN/A Expanded Problem Focused Brief (1-3) Brief (1) Detailed Extended (4+) Extended (2-9) Pertinent (1) Comprehensive Extended (4+) Complete (10+) Complete (2/3 or 3/3)

16. Examination u Problem Focused –Limited to affected body area or organ system –1 body area/organ system u Expanded Problem Focused –Affected body are or organ system and other symptomatic or related organ system –2-4 body areas/organ systems Detailed Detailed –Extended exam of affected body area(s) and other symptomatic or related organ systems –5-7 body areas /organ systems Comprehensive Comprehensive –Complete single system specialty exam or –Complete multi-system exam –8 or more body areas/organ systems

17. Medical Decision Making u Number of possible diagnoses and/or management options u Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed u Risk of complications, morbidity and/or mortality, associated with the patient’s presenting problem. Includes need for diagnostic procedures and management options

18. Medical Decision Making Decision Making Number of Diagnoses Amount of Data Risk of Complication Straight forward Minimal Min. or None Minimal Low Complexity LimitedLimitedLow Moderate Complexity MultipleModerateModerate High Complexity ExtensiveExtensiveHigh

19. Time Reporting: CPT Counseling Rule u Use when the time spent in ‘counseling and coordination of care’ > 50% of the E&M visit u The 3 key components of history, PE, MDM may be ignored –Only time is used to select the level of care u A summary of the ‘counseling’ discussion should be included with the note u Does not include screening time –Reported separately, with modifier (-25) Believe me, this is the best way to get paid for visits focused on developmental and behavioral problems

20. Preventive Medicine Services u E/M services performed in the absence of a significant problem/abnormality u Extent and focus depends on the patient’s age u Included counseling/anticipatory guidance/risk factor reduction

21. Preventive Medicine Services u New Patient Initial E/M of a new patient including an age and gender appropriate history, examination identification of risk factors, ordering of appropriate tests, and counseling RVU/2003 Medicare –99381 Age< 1 year2.75/$101.16 –99382 Ages 1-4 years2.96/$108.89 u Established Patient Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk factors, ordering of studies, and counseling RVU/2003 Medicare –99391 Age< 1 year2.08/$76.51 –99392 Ages 1-4 years2.33/$85.71

22. Office Visits-New Patient Codes9920199202992039920499205 History Problem Focused Expanded Problem Focused DetailedComprehensiveComprehensive Exam Problem Focused Expanded Problem Focused DetailedComprehensiveComprehensive Decision Making Straight Forward Low Complex Moderate Complex High Complex Time FF 1020304560 Key # 3 of 3

23. Office Visits-Established Patient Codes9921199212992139921499215 History Not Required Problem Focused Expanded Problem Focused Detailed Comprehens ive Exam Not Required Problem Focused Expanded Problem Focused Detailed Comprehens ive Decision Making Not Required Straight Forward Low Complex Mod Complex High Complex Time FF 510152540 Key # 2 of 3

24. Consultations u Consultation is a service provided by a physician whose opinion or advice is requested by another physician or other appropriate source u Consultant may initiate diagnostic and/or therapeutic services u Consultant must document: -Request for consultation (written or verbal) -Need for consultation -Opinion and services ordered and performed -Communication by written report back to the referring source

25. Office Consultation/ New or Est Code9924199242992439924499245 History Problem Focused Expanded Problem Focused DetailedComprehensiveComprehen. Exam Problem Focused Expanded Problem Focused DetailedComprehensiveComprehen. Decision Making Straight- forward Low Complex Mod Complex High Complex Time FF 1530406080 Key # 3 of 3

26. Prolonged Services (99354-99359) u Code series defining prolonged services by: –Site of service –Direct or without direct patient contact –Time u Reported in addition to other physician services, including E/M services at any level Total time for a given date, even if the time is not continuous Total time for a given date, even if the time is not continuous Time must be of 30 minutes or more Time must be of 30 minutes or more

27. Prolonged Services Direct Patient Care Outpatient Face to Face 99354 first 30-74 min Face to Face 99355 each add 30 min >75 Before or after Face to Face 99358 first 30-74 min of non-face to face Before or after Face to Face 99359 each add 30 min >75 min

28. Modifiers u Services altered by specific circumstance Tells insurer “this visit is different” - 21 Prolonged E/M Service -25 Significant separately identifiable E/M Service by the same physician on the same day Service by the same physician on the same day F Used to report developmental screening with E/M code -32 Mandated Services -52 Reduced Services