Transcript CODING 2001

Coding A Day…
in the Life of a
BUSY Pediatrician
2010
Richard H. Tuck, MD, FAAP
What’s New for
2010 ?
• CODES New CPT/ICD Codes
• VALUE- RBRVS – New RVU’s and CF
• PAYER PAYMENTAAP Private Sector Advocacy Program
State Pediatric Councils
National Class Action Law Suits
• PATIENTSCovered Benefit
Consumer Driven Health Care
• YOUR CONTRACT- Pay for Performance
CODING CHANGES
2010
ICD-9-CM 2010
Effective October 1, 2009
New Codes
• 756.72
• 756.73
Omphalocele
Gastroschisis
• 768.70
Hypoxic-ischemic encephalopathy,
unspecified
Mild
Moderate
Severe
• 768.71
• 768.72
• 768.73
ICD-9-CM 2010
Effective October 1, 2009
New Codes
•
•
•
•
•
•
779.31
779.32
779.33
779.34
789.7
799.82
Feeding problems in newborn
Bilious vomiting newborn
Other vomiting in newborn
Failure to thrive in newborn
Colic
Apparent life threatening event in infant
ICD-9-CM 2010
Effective October 1, 2009
New Codes
•
•
•
•
799.21
799.22
799.23
799.24
• 832.2
Nervousness
Irritability
Impulsiveness
Emotional Lability
Nursemaid’s elbow
ICD-9-CM 2010
Effective October 1, 2009
New V Codes
•
•
•
•
V15.83
V20.31
V20.32
V60.81
Personal history of underimmunization status
Health supervision for newborn under 8 days
Health supervision for newborn 8 to 28 days
Foster care (status)
ICD-9-CM 2010
Effective October 1, 2009
New V Codes
• Family disruption code additions:
– V61.97
Due to death of family member
– V61.08
Due to other extended absence of
family member
• V61.23 Counseling for parent-biologic child problem
• V61.24 Counseling for parent-adopted child problem
• V61.25 Counseling for parent/guardian foster child
problem
• V61.42 Substance abuse in family
ICD-9-CM 2010
Effective October 1, 2009
New V Codes
• V80.01
• V80.09
Special screening for traumatic brain injury
Special screening for other neurological
condition
• V87.44
• V87.45
• V87.46
Personal history of inhaled steroid therapy
Personal history of systemic steroid therapy
Personal history of immunosuppressive therapy
ICD-9-CM 2010
Effective October 1, 2009
Invalid Codes
•
•
•
•
768.7
779.3
799.2
V80.0
Hypoxic-ischemic encephalopathy
Feeding problems in newborn
Nervousness
Special screening neurological conditions
CPT 2010
Effective January 1, 2010
Concurrent Care and Transfer of Care
• Concurrent Care
– Similar services to same patient by more than
one physician on same day
• Transfer of Care
– Physician providing management relinquishes
responsibility to another accepting physician
– Consultation codes only if decision to accept
transfer of care cannot be made until initial
consultation visit
CPT 2010
Effective January 1, 2010
Consultations
• Consultation request documented in patient’s
record by either consulting or requesting
physician or other appropriate source
• Consultation initiated by patient/family –
report office visit or hospital E/M codes, not
consultation codes
CPT 2010
Effective January 1, 2010
Consultations
• F/U visits with consultant
– Established patient E/M codes
– Additional request for same or new problem from
another physician/source, use consultation codes
again
– Services constituting transfer of care use
appropriate new/established E/M codes
• Do not report both outpatient and inpatient
consultations related to the same inpatient stay
CPT 2010
Effective January 1, 2010
Prolonged Services w/o Direct Pt Contact
• 99358 – 99359
– May now be reported on a different date than the
primary service
Ex: extensive record review before or after visit
– Related to any level of E/M service, where direct
face to face care will or has occurred
– Time cumulative, not continuous
– Use only once per date
CPT 2010
Effective January 1, 2010
Vaccines/Toxoids
• Term “preservative free” includes products containing
either very little or no preservatives
• 90669 revised
– Pneumococcal vaccine – 7 valent
• ~907XX
– Pneumococcal vaccine – 13 valent
• 90378
– Respiratory Syncytial Virus – monoclonal antibody,
recombinant, 50 mg each
IMPORTANCE OF ACCURATE
APPROPRIATE CODING
• INCREASED REIMBURSEMENT
• DECREASED LIABILITY
• IMPROVED INFORMATION FLOW
Increase Reimbursement and
Decrease Liability Through
Physician Knowledge and Use of
Coding
Increase revenues by
increasing productivity
without working harder !
Basic Coding Systems
HCPCS:
CPT:
Complete coding system for all services furnished
Healthcare Common Procedural Coding System.
Coding for services furnished
Current Procedural Terminology
ICD-9-CM: Coding for diagnosis/reason for services
International Classification of Diseases, 9th
Revision Clinical Modification
RBRVS:
Assigns a relative reimbursement for CPT codes
Resource Based Relative Value Scale
Evaluation and Management Codes
7 Components
The “SCIENCE” of Coding
• Key
– History
– Examination
– Medical Decision Making
• Contributory
– Counseling
– Coordination of Care
– Nature of Presenting Problem
• Explicit
– Time – Only to assist physician in selection
History
Type
HPI
ROS
PFSH
Problem
Brief (1-3)
Focused (212)
Expanded
Brief (1-3)
Problem
Focused (213)
Detailed (214) Extended
(4+)
N/A
N/A
Brief (1)
N/A
Extended
(2-9)
Pertinent
(1)
Compre
Extended
hensive (215) (4+)
Complete
(10+)
Complete
(2/3 or 3/3)
Examination
• Problem Focused
(212)
– Limited to affected body area or organ system
– 1 body area / organ system
• Expanded Problem Focused
(213)
– Affected body area or organ system and
other symptomatic or related organ systems
– 2 – 4 body areas / organ systems
• Detailed
(214)
– Extended exam of affected body area(s) and
other symptomatic or related organ systems
- 5 – 7 body areas / organ systems
• Comprehensive
(215)
– Complete single system specialty exam or
– Complete multi-system exam
– 8 organ systems
Medical Decision Making
Decision
Making
Number of
Diagnoses
Minimal
Straight
forward (212)
Low
Limited
Complexity (3)
Moderate
Multiple
Complexity (4)
High
Extensive
Complexity (5)
Amount of Data Risk of
Complication
Min. or None
Minimal
Limited
Low
Moderate
Moderate
Extensive
High
* 2 of 3 elements met or exceeded
Time
• An explicit factor to assist in selecting the most
appropriate level of E/M services
• When counseling and/or coordination of care
are more than 50% of the face to face
encounter,then time is the key controlling factor.
• Utilize prolonged services codes (time based)
*Documentation in the medical record is a must
CODING A DAY …
• Services Provided:
–Face to Face
–Non Face to Face
–Procedures
–Additional Add on Services
6 AM
RISE AND SHINE !
• Telephone Call:
– Patient calls answering service early:
4 yo with sore throat and fever.
• Call returned and parent advised to call
office and schedule an ill appointment
in the morning
• How would you code for this service?
6 AM
RISE AND SHINE !
• A. 99212
• C. Not billable
service
• B. 99441 –
Physician telephone • D. 99358 –
Prolonged Service
call
non face/face
6 AM
RISE AND SHINE !
• Telephone Call:
– To Hospital Pediatric Unit
• Check status of patient and modify orders:
IV fluids for gastroenteritis and dehydration,
Advance diet
• How would you code for this telephone work ?
6 AM
RISE AND SHINE !
• A. 99221
• C. 99441 - Physician
Telephone call
(5-10 minutes)
• B. Not billable service
• D. 99358 –
Prolonged Services
non f/f (>30 minutes)
Telephone Services
CPT 2008
• 99441 Physician to est patient, parent or
guardian
2009 medicare
5 – 10 minutes of medical discussion ($12.62)
No related E/M service within previous 7 days
No related E/M service in next 24 hours or next
available appointment
• 99442 11 – 20 minutes
($24.89)
• 99443 21 – 30 minutes
($38.33)
7 AM
NURSERY TIME
• Hospital Nursery
– Term healthy newborn female
Routine history, examination,
medical decision making
Institute routine management
orders
• How would you code for these
services?
7 AM
NURSERY TIME
• A. 99431
• C. 99460
• B. 99221
• D. 99381
Key Concepts - Inpatient E/M
Coding
• Code for services only the day the patient is seen
(face to face)
• One E/M code per day
( few exceptions –25 Modifier)
• Time spent is “unit/floor time”
• Attending physician must see the patient and fulfill
and document criteria supporting code used
• Procedures should be coded separately
(few exceptions – Newborn /Critical care codes)
Normal Newborn Care
2009
•
•
•
•
•
•
99431
99432
99433
99435
99238
99239
Initial Hospital →
Other Setting →
Subsequent Hospital→
Same day Admit/Discharge →
Discharge ≤30 minutes
Discharge >30 minutes
• 99436 Attendance at delivery →
• 99440 Delivery Resuscitation →
•
•
•
•
•
•
99460
99461
99462
99463
Unchanged
Unchanged
• 99464
• 99465
7 AM
NURSERY TIME
• Hospital Nursery
– Term healthy newborn male
• Discharge: Routine history,
examination
• Extensive time spent dealing with
maternal anxiety and feeding
concerns
• Circumcision
• How would you code for these services?
7 AM
NURSERY TIME
• A. 99238
54150
(circumcision)
• C. 99460
54150
• B. 99231
54150
• D. 99239
54150
CPT Changes
2007
Circumcision Codes Revised
• 54150 Circumcision, clamp or other device,
with regional dorsal penile or ring block
– Use -52 modifier if w/o block
– Do not separately report 64450 for nerve block
• 0 day global code
• -25 modifier on associated E/M code (99239-25)
25 Modifier
• To support a separate and distinct evaluation
and management service the day of the
circumcision
– Code the appropriate E/M visit in addition to the
circumcision procedure
- Add modifier –25 to the E/M code
7:30 AM
NURSERY TIME
• Hospital Nursery
2 Day old infant with hyperbilirubinemia
• Phototherapy initiated for bilirubin of 17
following AAP guidelines
Expanded problem focused history and
examination, mod complexity med
decision making
• How would you code for this days services?
7:30 AM
NURSERY TIME
• A. 99433
• C. 99462
• B. 99232
• D. 99231
Subsequent Hospital Care
Code
99231
99232
99233
History
Problem
Focused
Detailed
Exam
Problem
Focused
Decision
Making
Time/ Floor
Straightfd/
Low
Complexity
15
Expanded
Problem
Focused
Expanded
Problem
Focused
Mod
Complexity
25
35
Key #
2 of 3
2 of 3
2 of 3
Detailed
High
Complexity
8 AM
NIGHT TIME CHALLENGE
• Pediatric Unit
4yo with gastroenteritis/dehydration, admitted from
ED evening during the night.
Calls made related to management
• Admission H&P, Orders, Discussion with parents;
Comprehensive Hx and Exam, Mod complexity MDM
(Extensive discussion with parents > 70 minutes)
How would you code for these time intensive services?
8 AM
NIGHT TIME CHALLENGE
• A. 99222
• C. 99214
• B. 99232
• D. 99253
Initial Hospital Care/ New or Est.
Code
99221
99222
History
Detailed or
Comprehensiv
e
Detailed or
Comprehensiv
e
Comprehensiv Comprehensiv
e
e
Decision
Making
Straightfd or
Low
Complexity
Mod
Complexity
High
Complexity
Time/ Floor
30
50
70
Key #
3 of 3
3 of 3
3 of 3
Exam
99223
Comprehensiv Comprehensiv
e
e
9 AM
THE FRONT LINE
• Arrive at office
Scheduled to start with a preventive medicine
visit at 9 am;
However, the telephone staff had an infant
with acute respiratory distress “come right in”.
Your nurse tells you this child is “sick” and
you need to see him now, disrupting your
schedule.
9 AM
THE FRONT LINE
• You see this patient, completing a detailed history,
detailed physical examination, and moderate
complexity decision making.
• The infant has a pulse ox of 95% in RA prior to
treatment
• An albuterol aerosol is given with dramatic
improvement; O2 sat improves to 98%
• The infant is sent home with instructions on use of
home aerosols
• F/U planned in two days
How would you Code for the E/M services for this
patient ?
9 AM
THE FRONT LINE
• A. 99213
• C. 99215
• B. 99214
• D. 99215
+ prolonged services
9 AM
THE FRONT LINE
• You see this patient, completing a detailed history,
detailed physical examination, and moderate
complexity decision making.
• The infant has a pulse ox of 95% in RA prior to
treatment
• An albuterol aerosol is given with dramatic
improvement; O2 sat improves to 98%
• The infant is sent home with instructions on use of
home aerosols
• F/U planned in two days
What other CPT codes should you bill for ?
9 AM
THE FRONT LINE
• A. 99058 – Emergency
office service
• B. 94760 – Pulse
Oximetry
• C. 94640 – Aerosol
94664 –
Aerosol/MDI
Teaching
• All of the above
Minor Office Procedures
Non Facility
CPT
Aerosol Rx only (X -76) 94640
Allergy injection (#1)
95115
#2 or more
95117
Cerumen Removal
69210
Lumbar Puncture
62270
Urine Catherization
51701
Venipuncture <3 yrs
36406
Venipuncture >3 yrs
36410
Venipuncture /Routine
36415
Finger/Heelstick
36416
RVU/ 2009 Medicare
0.37/ $13.34
0.29/ $10.46
0.35/ $12.62
1.25/ $45.08
4.14/$151.59
1.71/ $58.93
0.45/ $15.63
0.50/ $17.30
0.26/ $ 9.17
0.15/ $5.25
Examples of medical services
RVU/2009 Medicare
•
•
•
•
•
•
•
•
•
•
96360 - IV fluids, first hour
96372 - Injection SQ/IM
93000 – EKG/ w interpretation
93010 - EKG/ interpretation only
94010 - spirometry w/o bronchodilator
94060 - spirometry pre/post-bronchodilator
86580 -PPD
94664 – teaching nebulizer, MDI (-59)
92567 - tympanometry
94760 - pulse oximetry
1.57/ $56.62
.58/ $20.17
.58/ $20.17
.25/ $8.92
.91/ $31.20
1.6/$55.08
.20 / $6.91
.41/ $14.15
.49 / $17.57
.08/ $2.89
Special Services and Reports
“Modifier-Like” Codes
• 99000 – Handling and/or conveyance of a
specimen from office to laboratory
• 99050 - Services provided in office other than
regularly scheduled hours normally closed
• 99051 - Services provided in office during regularly
scheduled evening, weekend, holiday hours
• 99053 - Services provided 10PM to 8AM at 24 hour
facility
• 99058 - Office services on an emergency basis
Codes billed in addition to basic service
9:30 AM
WELL BABY TIME
• A two month old infant is scheduled for the initial
routine office visit. An age appropriate Hx and
PE are completed. There are no significant
problems. Age specific feeding, infant behavior
and anticipatory guidance is provided.
Immunizations are given following the AAP/ACIP
periodicity schedule.
• How would you code for the E/M work ?
9:30 AM
WELL BABY TIME
• A. 99213
• C. 99381
• B. 99214
• D. 99391
Preventive Medicine Services
• E/M services performed in the absence of a
significant problem/abnormality
• Extent and focus depends on the patient’s age
• Include counseling/anticipatory guidance/risk
factor reduction
• Do not include office procedures, ancillary
services, and immunizations
Preventive Medicine Services
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/ 2009
Medicare
99381 Age < 1 year
2.51/ $ 90.53
99382 Ages 1 – 4 years
2.73/ $ 98.46
99383 Ages 5 – 11 years
2.71 /$ 97.74
99384 Ages 12 – 17 years
2.95/ $106.40
99385 Ages 18 – 39 years
2.95/ $106.40
Preventive Medicine Services
Established Patient
Periodic reevaluation and management requiring an
age and gender appropriate history, examination
identification of risk factors, ordering of studies, and
counseling
RVU/ 2009 Medicare
99391 Age < 1
2.09/ $75.38
99392 Ages 1 – 4 years
2.33/ $84.04
99393 Ages 5 – 11 years
2.32 /$83.67
99394 Ages 12 – 17 years
2.55/ $91.97
99395 Ages 18 – 39 years
2.56/ $92.33
9:30 AM
WELL BABY TIME
• A two month old infant is scheduled for the initial
routine office visit. An age appropriate Hx and PE
are completed. There are no significant problems.
Age specific feeding, infant behavior and anticipatory
guidance is provided. Immunizations are given
following the AAP/ACIP periodicity schedule.
(DTap-Hib-IPV; Prevnar;Hep B; RotaTeq)
• How would you code for the immunization work ?
Do you need a -25 modifier on the associated E/M
code ?
9:30
WELL BABY TIME
• A. 90471
90472 X 2
90474
Immunization products
• C. 90465
90466 X 2
90468
Immunization products
• B. 90471
90472 X 2
90473
Immunization products
• D. 90465
90466 X 2
90467
Immunization products
Immunizations
• Bill and Document ALL:
– E/M Visit
• Office Visit, Preventive Medicine
– Immunization Administration
• 90471 – 90474
• 90465 - 90468 (2005 Peds specific)
– Vaccine/Toxoid
• 90476 – 90749
• Link to ICD Diagnoses
– V20.2 Well Child
– CSHCN Diagnosis
– + Specific Vaccine V Codes
EXISTING CPT CODES 2004
Vaccine Administration
• 90471
Immunization administration (includes percutaneous,
intradermal, subcutaneous, or intramuscular injections); one
vaccine (single or combination vaccine/toxoid)
• 90472
each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for primary
procedure)
• 90473
Immunization administration by intranasal or oral
route; one vaccine (single or combination vaccine/toxoid)
• 90474
each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for primary
procedure)
2005 “NEW” CPT CODES
Vaccine Administration
• 90465
Immunization administration under 8 years of age
(includes percutaneous, intradermal, subcutaneous, or
intramuscular injections) when the physician counsels the
patient/family; first injection (single or combination
vaccine/toxoid), per day
• 90466 each additional injection (single or combination
vaccine/toxoid), per day
• 90467 Immunization administration under age 8 years
(includes intranasal or oral routes of administration) when the
physician counsels the patient/family; first administration (single
or combination vaccine/toxoid), per day
• 90468 each additional administration (single or combination
vaccine/toxoid), per day (List separately in addition to code for
primary procedure)
Vaccine Administration
RVUs for 2009
• Values - Existing codes
RVU 2009 medicare
– 90471 – 0.58/ $20.92
– 90473 – 0.38/ $13.71
• Values - New codes
– 90465 – 0.58/ $20.92
- 90467 -0.38/ $13.71
RVU 2009 medicare
90472 – 0.29/ $10.46
90474 – 0.25/ $ 9.02
90466 – 0.29/ $10.46
90468 – 0.28/ $10.10
? -25 Modifier
10:00 AM
? WELL BABY TIME
• A 6 month infant boy presents for a scheduled
preventive visit. His mother is worried about the cold
and fever he has had for several days. An age and
gender appropriate Hx and PE are completed, in
addition to an extended Hx addressing the ongoing
illness. A Dx of otitis media is made and the infant is
treated with po amoxicillin. His mother is not
comfortable with proceeding with immunizations. It is
agreed that she will return in several weeks for a nurse
only visit to obtain these important vaccines.
• How would you code for this office visit ?
10:00 AM
? WELL BABY TIME
• A. 99391
• C. 99391
99213-25
• B. 99214
• D. 99391
99212-25
Preventive Medicine vs
E/M Office Visit ?
What do you do if a significant illness or problem
is found at a preventive medicine visit?
25 Modifier
• If a significant problem/abnormality is found at a
preventive medicine visit:
– Code the appropriate E/M visit in addition to
99381 – 99395
- Add modifier –25 to the E/M code
- If not significant code only 99381 – 99395
- Option: Have patient return for a separate E/M
visit for problem/abnormality found
25 Issues
• Coverage
NCCI Edits
• Copays
• Separate Documentation
• Supporting Diagnosis
10:30 AM
COMPLETE PHYSICAL TIME
• A 5yo est patient presents for her school PE.
She has been a healthy girl with no significant
parent concerns. An age and gender appropriate
Hx and PE are completed. Following Bright
Futures guidelines, hearing and vision screening
are completed. A Hgb is also obtained, and
immunizations are given.
• How would you code for the E/M service ?
10:30 AM
COMPLETE PHYSICAL TIME
• A. 99393
• C. 99214
• B. 99383
• D. 99215
10:30 AM
COMPLETE PHYSICAL TIME
• A 5yo girl presents for her school PE. She has been a
healthy girl with no significant parent concerns. An age
and gender appropriate Hx and PE are completed.
Following Bright Futures guidelines, hearing and vision
screening are completed. A Hgb is also obtained, and
immunizations are given.
• Can you code for the screening work provided ?
Do you need a -25 modifier ? How is it attached ?
10:30 AM
COMPLETE PHYSICAL TIME
• A. Hearing and Vision
• C. Hgb testing
testing included in
recommended
preventive medicine visit
36416 (fingerstick)
85018 (Hgb)
• B. 92551 (hearing)
99173 (vision)
• D. -25 modifier required
99393-25
Screening services
•
•
•
•
RVU/ 2009 Medicare
92583 - hearing screen, select picture
.91/ $31.30
92551 - hearing screen, pure tone
.29/ $10.46
92552 –hearing screen, pure tone threshold.59/ $21.28
99173 - visual acuity screening
.07/ $2.52
– may be reported w/ preventive care codes,
not if part of an E/M service of the eye
10:30 AM
COMPLETE PHYSICAL TIME
• A 5yo girl presents for her school PE. She has been a
healthy girl with no significant parent concerns. An age
and gender appropriate Hx and PE are completed.
Following Bright Futures guidelines, hearing and vision
screening are completed. A Hgb is also obtained, and
immunizations are given. (DTaP; IPV; MMR; Varivax)
• How would you code for the immunizations
provided ?
10:30 AM
COMPLETE PHYSICAL TIME
• A. 99393
90465
90466 X 3
• C. 99393-25
90465
90466 X 3
• B. 99393
90471
90472 X 3
• D. 99393-25
90471
90472 X 3
Special Office Services
2008 RVU/ $ Medicare
• Insurance Forms
• Charge for Forms!
99080
000/ 000
11 AM
MAKE ME BETTER TIME
• A 12 yo teenager est patient presents with a
severe sore throat for 2 days, associated with a
fever and swollen glands. An expanded
problem focused Hx and PE are done. A strep
FA is obtained and treatment with
acetaminophen/ibuprofen reviewed.
• How would you code for this patient ?
11AM
MAKE ME BETTER TIME
• A. 99212
87880 (strep FA)
• C. 99214
87880 (strep FA)
• B. 99213
87880 (strep FA)
• D. 99394
87880 (strep FA)
Key Concepts – Outpatient E/M
Coding
• Time spent is “face to face”
• One E/M code per day
– Few exceptions:
• -25 modifier
• Prolonged services codes
• Attending physician must see the patient and fulfill /
document criteria supporting code used
• Procedures and other services should be coded
separately
– May require modifiers (-25 on the E/M code)
Office Visits – New Patient
Codes
99201
99202
History
Problem
Focused
Exam
Problem
Focused
Decision
Making
Time FF
Key #
99203
99204
99205
Expanded Detailed
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
Compre
hensive
Compre
hensive
Compre
hensive
Straight
forward
Straight
forward
Low
complex
Moderate
complex
High
complex
10
3 of 3
20
3 of 3
30
3 of 3
45
3 of 3
60
3 of 3
Office Visits – Established Patient
Codes
99211
99212
99213
99214
99215
History
Not
Required
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
Exam
Not
Required
Problem
Focused
Detailed
Compre
hensive
Decision
Making
Time FF
Not
Required
5
Straight
forward
10
Expanded
Problem
Focused
Low
Complex
15
Mod
Complex
25
High
Complex
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
The ART of Coding
• The “FEEL” – Established Patient
– 99211 - Nurse Visit
– 99212 - Easy, Brief Problems
– 99213 - Average, Usual Problems
– 99214 - “ OH NO !”
– 99215 - “ Just Ran a Marathon”
11:15
I’M STILL SICK TIME !
• Our patient returns 5 days later. She is miserable,
cannot swallow, and looks dry. She is congested and
has been sleeping all the time. An detailed Hx and PE
is completed. Lab work including a Mono spot, chem-8,
and urinalysis are ordered. Extensive discussion re the
DDx, Rx and F/U is completed. The patient is treated
with a short course of steroids when the Mono spot is
positive.
• How would you code for these services ?
11:15
I’M STILL SICK TIME !
• A. 99213
36415 (venipuncture)
99000 (specimen transfer)
• C. 99214
36415 (venipuncture)
99000 (specimen transfer)
• B. 99233
36415 (venipuncture)
99000 (specimen transfer)
• D. 99215
36415 (venipuncture)
99000 (specimen transfer)
Codes
99211
99212
99213 99214
99215
History
Not
Required
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
HPI 1-3
ROS N/A
PFSH N/A
HPI 1-3
ROS 1
PFSH
N/A
Problem
Focused
Expanded Detailed
Problem
Focused
1 Area
2-4 Areas 5-7 Areas >8 Areas
Required
Elements
Exam
Not
Required
Required
Elements
HPI 4+
HPI 4+
ROS 2-9 ROS 10+
PFSH 1/3 PFSH 2/3
Compre
hensive
Decision
Making
Not
Required
Straight
forward
Low
Complex
Mod
Complex
High Complex
Time FF
5
10
15
25
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
11:30
QUICK SICKIE TIME
• A 13yo boy comes in announcing he has poison
ivy. A brief Hx and PE support his diagnosis. It is
in several small patches on his extremities.
You treat with a topical steroid prescription.
• How would you code for this quickie ?
11:30 AM
QUICKIE SICKIE TIME
• A. 99213
• C. 99211
• B 99214
• D. 99212
11:45
LUNCH TIME/ DISASTER TIME
• A 15 yo patient of your partner is scheduled with a cc
of “anxiety attacks”. She is inappropriately scheduled
in a 10 minute ill appointment time. You complete a
comprehensive Hx, extended PE, and provide
extensive counseling for this adolescent who is
depressed and suicidal. Total face to face time for this
encounter is 50 minutes, with 30 minutes spent
counseling and coordinating care for this crisis.
• How would you code for this total loss of your lunch
time ?
11:45 am
LUNCH TIME/DISASTER TIME
• A. 99214
• C. 99354
(prolonged services)
• B. 99215
• D. 99204
Use Time !
Time
• An explicit factor to assist in selecting the most
appropriate level of E/M services
• When counseling and/or coordination of care
are more than 50% of the face to face
encounter,then time is the key controlling factor.
• Utilize prolonged services codes (time based)
*Documentation in the medical record is a must
Office Visits – Established
Patient
Codes
99211
99212
99213
99214
99215
History
Not
Required
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
Exam
Not
Required
Problem
Focused
Compre
hensive
Decision
Making
Not
Required
Straight
forward
Expanded Detailed
Problem
Focused
Low
Mod
Complex Complex
Time FF
5
10
15
25
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
High
Complex
LUNCH TIME +
• Your lunch time has been lost, but you are still
on schedule. You have time to make one 10
minute phone call to a patient who is having
issues with toilet training her 3yo son. This is not
related to a previous visit and does not result in
a scheduled E/M visit.
• How would you code for this time consuming
work? Is this a billable service?
LUNCH TIME +
• A. 99441
• C. Not a billable service!
• B. 99358 (1st hour non f/f) • D. 99211
Telephone Services
CPT 2008
• 99441 Physician to est patient, parent or
guardian
2009 medicare
5 – 10 minutes of medical discussion ($12.62)
No related E/M service within previous 7 days
No related E/M service in next 24 hours or next
available appointment
• 99442 11 – 20 minutes
($24.89)
• 99443 21 – 30 minutes
($38.33)
Non Face-to-Face Non-Physician Services
CPT 2008
• Telephone – by qualified non-physician health care
professional
No related E/M service previous 7 days
No related other service in next 24 hours or
next available appointment
2009 medicare
98966 5 – 10 minutes medical discussion ($12.26)
98967 11 – 20 minutes
($24.89)
98968 21 – 30 minutes
($37.15)
Online Medical Evaluation
CPT 2008
• 99444 Online E/M service provided by a
physician to an est patient, parent, guardian or
health care provider Not originating from
related E/M service in previous 7 days
In response to patient’s online inquiry
Using internet or similar communications
network Requires “timely response”
Permanent storage of encounter
($0.00)
Non Face-to-Face Non-physician Services
CPT 2008
• Online Medical Evaluation
• 98969 Online assessment and management,
by non-physician health care professional
No related assessment and management service
in previous 7 days
Using internet or similar electronic communication
network
In response to patient’s on line inquiry
($0.00)
Timely response with permanent storage of
encounter
TAKE A BREAK !
1 PM
DAILY GRIND TIME
• You settle into the afternoon pace with an 18 month old
female scheduled for a preventive medicine visit. This
is completed using a template for an 18 month visit.
ASQ developmental and MCHAT autism screenings
are completed following Bright Futures guidelines.
The patient will receive Hep A #2 and HIB #4
immunizations.
• How would you code for the E/M and screening
services?
1 PM
DAILY GRIND TIME
• A. 99392
Screening included
• C. 99382
96110 X 2
• B. 99392
96110 X 2
(standardized dev screening)
• D. 99392-25
96110
96110-59
Developmental Testing Codes
Central Nervous System Assessments/Tests
• 96110 Developmental Testing, limited
• Performed by office nurse or other trained nonphysician personnel
• Parent/guardian report of behavior
• RVU 0.36 $12.98 2009 medicare
• Modifier –25 may be attached to associated E/M visit
• Modifier -59 to multiple additional tests
• Interpretation and report
Documentation in progress report of E/M visit
96110 Examples
•
•
•
•
•
•
•
•
Ages and Stages Questionnaire (ASQ)
Brigance Early Preschool
Developmental Profile II
Early Language Milestone Scales
PEDS
PDQ
Vanderbilt
MCHAT
• NOT direct physician observation or
general developmental assessment with
checklist of milestones appropriate for age
1 PM
DAILY GRIND TIME
• You settle into the afternoon pace with an 18
month old female schedule for a preventive
medicine visit. This is completed using a
template for an 18 month visit. ASQ
developmental and MCHAT autism screenings
are completed following Bright Futures
guidelines. The patient will receive Hep A #2
immunization.
• How would you code for the immunization?
1 PM
DAILY GRIND TIME
• A. 99392
Immunizations included
• C. 99382
99465
• B. 99392
99471
• D. 99392-25
99465
Preventive Medicine Ancillary Services
Screening
RVU/ 2009 Medicare
Hearing testing - Select picture
92583
.91/ $31.30
Hearing testing – Puretone
92551
.29/ $10.46
Hearing testing – Puretone(threshold) 92552
.59/ $21.28
Vision screening
99173
.07/ $2.52
Developmental Screening
96110
.36/ $12.98
Lab
Hemoglobin
85018
.10/ $3.45
Urine (dip only)
81002
.08/ $2.78
Routine Venipuncture
36415
.26/ $9.17
Finger/Heel Stick
36416
.15/ $5.25
Immunizations
Immunization administration 90471/90465
.58/ $20.92
90472/90466
.29/ $10.46
Vaccine/Toxoid product
90476-90479
Other
Injection/other
96372
.58/ $20.17
1:15 PM
? CONSULTATION TIME ?
• Your 3yo established patient with significant caries and
associated dental abscess problems is scheduled for
general sedation and teeth extraction at the ambulatory
surgical center. She is scheduled for a preop visit. The
patient has an Expanded problem focused history and
examination. She has no significant problems. The
preop form is completed.
• How would you code for this visit for your established
patient?
1:15 PM
DENTAL PREOP
• A. 99214
• C. 99242
• B. 99241
• D. 99252
Provide Consultations !
99241-99245
• Payment is 25-42% higher than corresponding
new patient office visit codes, and…
• Documentation requirements for History, Exam,
and MDM are the same!
• Consult codes are problem-based and can be
used for new or established patients
Consultations – 5 R’s - 2008
REASON:
Medically necessary
REQUEST: By another physician or other appropriate source
RENDER:
May initiate diagnostic and/or therapeutic
services
REPORT:
By written report back to the requesting source
RETURN:
Patient back to requesting physician/source
Office Consultation/ New or Est
Code
99241
99242
History
Problem
Focused
Exam
Problem
Focused
99243
99244
99245
Expanded Detailed
Problem
Focused
Compre
hensive
Compre
hensive
Compre
hensive
Compre
hensive
Decision
Making
Expanded Detailed
Problem
Focused
Straightfd Straightfd Low
Complex
Mod
Complex
High
Complex
Time FF
15
30
40
60
80
Key #
3 of 3
3 of 3
3 of 3
3 of 3
3 of 3
Inpatient Consult / New or Est.
Code
99251
99252
History
Problem
Focused
Exam
Problem
Focused
Decision
Making
Time/unit
Key #
99253
99254
99255
Expanded Detailed
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
Compre
hensive
Compre
hensive
Compre
hensive
Straightfd
Straightfd
20
40
Low
Complex
55
Mod
Complex
80
High
Complex
110
3 of 3
3 of 3
3 of 3
3 of 3
3 of 3
Code for extensive medical
services
• $ OV < Prev Med < Consultation
1:30 PM
DAILY GRIND (PLUS) TIME
• A 12 yo boy is scheduled for a sports physical. A
complete preventive medicine visit is completed. He
has a history of mild intermitent asthma, and is
currently managed with a steroid inhaler and prn
albuterol MDI. Spirometry is completed supporting
good control. He receives scheduled immunizations
and is instructed in the use of his MDI.
• How would you code for this “physical” ?
• How would you code for all the associated services?
1:30 PM
DAILY GRIND (PLUS) TIME
• A. 99394
99213
94010 (spirometry)
• C. 99394
• B. 99394-25
99213
94010 (spirometry)
• D. 99394
99213-25
94010 (spirometry)
Examples of medical services
RVU/2009 Medicare
•
•
•
•
•
•
•
•
•
•
96360 - IV fluids, first hour
1.57/ $56.62
96372 - Injection SQ/IM
.58/ $20.17
93000 – EKG/ w interpretation
.58/ $20.17
93010 - EKG/ interpretation only
.25/ $8.92
94010 - spirometry w/o bronchodilator
.91/ $31.20
94060 - spirometry pre/post-bronchodilator 1.6/$55.08
86580 -PPD
.20 / $6.91
94664 – teaching nebulizer, MDI (-59)
.41/ $14.15
92567 - tympanometry
.49 / $17.57
94760 - pulse oximetry
.08/ $2.89
2 PM
CHALLENGE OF THE DAY TIME
• A 1 mos infant female with Down’s syndrome
has just been discharged from the NICU. She
has a complex VSD and congestive heart
failure. She has a feeding tube and is on a CA
monitor. Records are reviewed prior to the visit,
and calls made to the home nursing service.
• How would you code for the work provided for
this complex CSHCN patient?
2 PM
THE CHALLENGE !
• A. 99215
• C. 99205
99358
(prolonged services non f/f)
• B. 99205
• D. 99205-25
99358
Prolonged Services
(99354-99359)
• Code series defining prolonged services by:
– Site of service
– Direct or without Direct patient contact
– Time
• Reported in addition to other physician service,
including E/M services at any level
• Total time for a given date, even if the time is
not continuous
• Time must be of 30 minutes or more
Prolonged Services
Direct Patient
Care
Face to Face
Face to Face
Before or after
Face to Face
Before or after
Face to Face
Outpatient
Inpatient
99354 first hour
> 30 min
99355
each add 30 min
> 75 min
99358 first hour
> 30 min
99359
each add 30 min
> 75 min
99356 first hour
> 30 min
99357
each add 30 min
> 75 min
99358 first hour
> 30 min
99359
each add 30 min
> 75 min
2:30 PM
NON PHYSICIAN WORK TIME
• A parent comes in for an ADHD medication visit.
It has been one month since her son’s
scheduled physician visit. He is doing well on his
current dose of stimulant medication, sleeping
well, and eating well. Some minor home
behavioral issues are discussed. The
prescription written by the physician is given to
the parent, and a visit scheduled in 1 month for
the next ADHD f/u appt.
• How would you code for this non-physician visit?
2:30 PM
NON PHYSICIAN WORK TIME
• A. 99212
• C. 99211
• B. Not billable service
• D. Not subject to copay
2:45 PM
NON PHYSICIAN WORK TIME
• A parent comes in for a catchup immunization for her 6
month infant who had a febrile URI at the previous
preventive medicine visit. He has some persisting
congestion. The nurse does an interval Hx, vital signs,
and listens to the infants chest with a stethescope. A
decision is made to proceed with immunizations, and a
visit scheduled in 6 weeks for the next scheduled
preventive medicine visit. This E/M visit is carefully
documented.
• How would you code for this non-physician visit?
2:45 PM
NON PHYSICIAN WORK TIME
• A. No billable service
• C. 99211-25
99465
99466
99478
+ immunization products
• B. 99211
99465
99466
99478
+ immunization products
• D. 99211-25
99471
99472
99478
+ immunization products
99211
• Typical Presenting Problems
Nurse Visit (Provides an E/M Service)
– BP Check
– Throat Culture
– Neonate Weight Check
– ADHD Medication Refill
– PPD Check
– Dressing changes
– Simple suture removal
– Immunizations – in addition to administration
code
• Document !
• 99211 Typically Triggers a Copay
3 PM
PROCEDURE TIME
• A mother brings in her 3 yo girl with a cc of “bad
breath”. She has “tried everything” to get rid of it.
After an expanded Hx and PE, she is taken to
the treatment room where a makeup sponge is
removed using bayonette forceps.
• How would you code for this procedure?
3 PM
PROCEDURE TIME
• C. 99213
• A. 30300
30300
(removal of nasal foreign
body)
• B. 99212
30300
• D. 99213-25
30300
PROVIDE MORE PROCEDURES
!
CODE FOR PROCEDURES !
Code for Those Procedures!
Provide more services with procedures (nonfacility):
RVU/$2009 Medicare
Burn treatment/first degree
Burn treatment/debridement
Chemocautery/granuloma
Chemocautery/epistaxis
Circumcision/newborn
16000 (00)
16020 (00)
17250 (00)
30901 (00)
54150 (10)
Facility
1.72/$60.73
2.02/$70.52
1.84/$66.36
2.64/$99.22
6.63/$239.12
2.81/$101.35
Code for Those Procedures!
Provide more services with procedures (nonfacility):
RVU/2009 Medicare
Foreign body removal/ear
Foreign body removal/nose
FB removal/subcutaneous
Incision&Drainage/Simple
Wart removal (1-14)
Wart removal (15 or >)
Wound repair/dermabond
69200
30300
10120
10060
17110
17111
12011
(00)
(00)
(10)
(10)
(10)
(10)
(10)
3.02/$108.92
5.47/$186.55
3.33/$120.10
2.72/ $98.10
2.70/ $97.38
3.20/ $115.41
3.87/$135.84
Orthopedic Procedures
2009
RVU/Medicare
Subluxation of radial head
Closed Rx radial fx
Closed Rx distal phalanx fx
Closed Rx proximal or middle
phalanx fx
Closed Rx toe fx
Closed Rx great toe fx
Closed Rx clavicle fx
Splint forearm
24640
25500
26750
26720
2.89/ $104.23
6.23/ $218.75
4.25/ $149.09
4.55/ $159.24
28510
28490
23500
29125
2.87/ $100.44
3.30/ $114.82
5.12/ $184.66
1.63/ $56.82
Use HCPCS Codes for Supplies
• If not included as standard practice expense
for the procedure
(Practice expense component of RBRVS)
• CPT 99070
General Nonspecific code for supplies
• HCPCS codes are preferable
Alphanumeric
HCPCS Codes
Used to report supplies
• J1100 - Dexamethasone injection, 1 mg
• J0170 - Epinephrine
• J0696 - Ceftriaxone, per 250 mg
• J7613 - Albuterol for inhalation, 1 unit dose
3:30 PM
FUSSY BABY TIME
• A 2 mos infant has been fussy since birth. He is
difficult to console and has been very spitting,
with vomiting once/ day. There have been no
other symptoms of illness. A detailed history and
detailed examination are completed. 15 minutes
of face to face time are recorded for the visit.
• How would you code for this fussy baby and
fussy parent?
3:30
FUSSY BABY TIME
• A. 99212
• C. 99214
• B. 99213
• D. 99215
4 PM
TEEN TROUBLE TIME
• A 13yo boy has been failing in school and was
suspended today for threatening another student. Your
assessment includes a plan to evaluate for ADHD/
learning disabilities, as well as, obtain counseling for
his significant home and school adjustment problems.
Total face to face time for the visit is 45 minutes, with
30 minutes spent counseling and coordinating care
related to the issues, Dx, and Rx options.
• How would you code for this troubled teen visit?
4 PM
TROUBLED TEEN TIME
• A. 99214
• C. 99213
• B. 99215
• D. 99213
99354
(prolonged services f/f)
Office Visits – Established
Patient
Codes
99211
99212
99213
99214
99215
History
Not
Required
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
Exam
Not
Required
Problem
Focused
Compre
hensive
Decision
Making
Not
Required
Straight
forward
Expanded Detailed
Problem
Focused
Low
Mod
Complex Complex
Time FF
5
10
15
25
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
High
Complex
Documentation/ ICD 9 CM
• ICD coding should support higher levels of coding
(medical necessity)
• 99213 to 99215
• Code multiple diagnoses
• Code comorbidities
• Document chronic condition when an acute problem is
presented
– Asthma
– Diabetes mellitus
– Prematurity and related problems
4:30 PM
THE STANDARD ILL VISIT
• A new patient 4 yo girl presents with several
days of burning pain with urination. An
expanded problem focused history and
expanded problem focused examination are
completed. A urinalysis with microscopic
analysis is done. The diagnosis is vulvitis and
sitz baths are recommended.
• What would you code for this bread and butter
pediatric visit?
4:30 PM
THE STANDARD ILL VISIT
• A. 99213
81000 (u/a with micro)
• C. 99202
81000 (u/a with micro)
• B. 99203
81000 (u/a with micro)
• D. 99204
81000 (u/a with micro)
4:45 PM
ANOTHER ONE!
• A 3yo female presents with twelve hours of
fussiness and vomiting. She does not have fever
and is urinating well. An expanded problem
focused history and examination are completed.
Slowly advancing clear fluids is reviewed, as
well as, when to call if her condition worsens.
• How would you code for this everyday patient?
4:45 PM
ANOTHER ONE!
• A. 99212
• C. 99213
• B. 99214
• D. 99215
4:45 PM
ANOTHER SICKER ONE!
• A 5yo female presents with one day of vomiting. She
has a temp of 101, diarrhea, and lethargy. She is
urinating less and not tolerating “anything”. A detailed
history and examination are completed. A negative
urinalysis is obtained with a specific gravity of 1.020.
Management is reviewed: slowly advancing clear
fluids, treatment of fever, and when to call.
• How would you code for this everyday patient?
4:45 PM
ANOTHER SICKER ONE!
• A. 99212
81002 (dip urinalysis)
• C. 99213
81002
• B. 99214
81002
• D. 99215
81002
Codes
99211
99212
99213 99214
99215
History
Not
Required
Problem
Focused
Expanded Detailed
Problem
Focused
Compre
hensive
HPI 1-3
ROS N/A
PFSH N/A
HPI 1-3
ROS 1
PFSH
N/A
Problem
Focused
Expanded Detailed
Problem
Focused
1 Area
2-4 Areas 5-7 Areas >8 Areas
Required
Elements
Exam
Not
Required
Required
Elements
HPI 4+
HPI 4+
ROS 2-9 ROS 10+
PFSH 1/3 PFSH 2/3
Compre
hensive
Decision
Making
Not
Required
Straight
forward
Low
Complex
Mod
Complex
High Complex
Time FF
5
10
15
25
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
5:00 PM
EAR TIME
• A 2 yo est patient presents with fussiness,
congestion, and pulling at her ears. She is
afebrile. An expanded problem focused Hx and
PE are completed. Cerumen is removed from
both ears to visualize the tympanic membranes.
A diagnosis of otitis media is made and the
patient treated with po antibiotics.
• How would you code for this frequently
encountered problem?
5:00 PM
EAR TIME
• A. 99212
• C. 99214
(includes cerumen
removal)
• B. 99213
69210 (cerumen removal)
• D. 99213-25
69210 (cerumen removal)
5:15 PM
SQUEEZE ‘EM IN TIME
• A 6 yo boy fell from a swing set and has refused
to move his left arm since. On physical
examination, he has localized swelling and pain
of the mid L clavicle. An Xray is obtained. A
sling is applied and analgesics recommended.
• How would you code for this orthopedic
procedure?
5:15 PM
SQUEEZE ‘EM IN TIME
• A. 99213
73000 Xray clavicle
A4565 Sling
• C. 23500 (Rx fx clavicle)
73000 Xray clavicle
A4565 Sling
• B. 99214
73000 Xray clavicle
A4565 Sling
• D. 99212-25
23500
73000 Xray clavicle
A4565 Sling
Orthopedic Procedures
2009
RVU/Medicare
Subluxation of radial head
Closed Rx radial fx
Closed Rx distal phalanx fx
Closed Rx proximal or middle
phalanx fx
Closed Rx toe fx
Closed Rx great toe fx
Closed Rx clavicle fx
Splint forearm
24640
25500
26750
26720
2.89/ $104.23
6.23/ $218.75
4.25/ $149.09
4.55/ $159.24
28510
28490
23500
29125
2.87/ $100.44
3.30/ $114.82
5.12/ $184.66
1.63/ $56.82
Fracture Care
Which is best ?
• Fracture Care Global (90 day)
– All visits in global period included
– Strapping, splinting, casting included
– X-ray, Supplies separately billed
– Unrelated E/M service separately billed (-25)
– OR Decision for procedure separately billed (-57)
VS.
• E/M coding Plus
– All visits separately billed
– Strapping, splinting, casting billed separately
– X-ray, Supplies separately billed
6 PM
STAY LATE TIME
• A parent calls at 5pm with a 4 yo crying with a
severe earache. The office is kept open and the
patient arrives at 6pm. The patient is febrile and
irritable. A detailed history and examination are
completed. A diagnosis of otitis media is made
and the patient treated with amoxicillin.
• How would you code for this stay late patient?
6 PM
STAY LATE TIME
• A. 99213
• C. 99214-25
99050
• B. 99214
99050
• D. 99213
99051
Special Services and Reports
“Modifier-Like” Codes
• 99050 - Services provided in office other than
regularly scheduled hours normally closed
• 99051 - Services provided in office during regularly
scheduled evening, weekend, holiday hours
• 99053 - Services provided 10PM to 8AM at 24 hour
facility
Codes billed in addition to basic service
DOCUMENT !
DOCUMENT !
DOCUMENT !
AAP Your CODING CONNECTION
Coding & Reimbursement Resources
• National AAP Coding Hotline:
[email protected] or 800/433-9016 ext
4022; free service to members and their office
staff
• Coding publications: Coding for Pediatrics,
Pediatric Coding Companion, Quick Reference
Guides, ICD-9-CM Flipchart, RBRVS Brochure,
AAP News Coding Corner
A Hundred Years From Now
It will not matter what my bank account
was,
the sort of house I lived in,
or the kind of car I drove…
But the world will be different
Because I was important in the life of a
CHILD