Transcript AAP Screening-Developmental Screening: Billing and Coding

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.
Importance of Accurate Coding
 Improved
Information Processing
– Accurate diagnostic coding requires analyzing all provided
information (subjective and objective)
 Decreased
Liability
– Documentation

Medico-legal
– Compliance
 Increased
Reimbursement
– One minute of extra work can result in an increased code
level
Diagnostic Codes
 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 ICD10
ICD-9 Codes
 Code
to the highest degree of specificity
 Code to the highest degree of certainty for the
encounter such as symptoms, signs, abnormal test
results
 Probable, suspected, questionable, or rule out should
not be coded
 List the ICD-9/10 code that is identified as the main
reason for the service first, then list co-existing
conditions
 Chronic disease treated on an ongoing basis may be
coded
 Do not code for conditions previously tx that no longer
exist
Developmental Coding: Examples
 783.42
Delayed milestones
 728.85 Hypertonia
 315.31 Language disorder, developmental
 315.9
Learning disorder, NOS
 348.3
Static encephalopathy
Current Procedural Terminology
(CPT)
 Published
 Listing
by the AMA
of the codes and descriptions for
procedures, services and supplies
 Used
to bill insurance carriers
CPT Coding
5 Basic Principles of Use
 Practitioner
should select diagnosis and procedure
codes
 Document patient’s services to support codes
(compliance)
 Use separate codes for different encounters
 Learn to use modifiers, testing and add-on codes
 Design a superbill/computerized routing sheet
“RVU Review”
 Resource
Based Relative Value Scale (RBRVS)
 Relative Value Units (RVUs): “The Coin of the
Realm”
 A numerical value (relative reimbursement) assigned
to a CPT code
 Calculated on
–
–
–
–
Amount of physician work
Practice expenses
Malpractice cost
Service location (office vs. hospital)
RVU Components of Physician Work
 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
RVUs  Cash
are assigned by the Relative Value
Scale Update Committee (RUC)
 Each 3rd party payer that uses RVus in
payment calculations applies its own
‘conversion factor’ (CF)
 The CF is multiplied by the RVU to
determine that payor’s payment
 RVUs
TABLE 2
CPT Codes for Developmental Screening
Developmental Screening
 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)
Developmental Testing
 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
Evaluation and Management (E/M)
Codes
 Bill
based on level of complexity- 3 major
components
– History
– Physical Exam
– Medical Decision Making (MDM)
 Bill
based on time
– Only if counseling and coordination of care >
50% of visit
“Complexity” Billing: History
Type
HPI
ROS
PFSH
Problem Focused
Brief (1-3)
N/A
N/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)

Problem Focused
Examination
– Limited to affected body area or organ system
– 1 body area/organ system

Expanded Problem Focused
– Affected body are or organ system and other symptomatic or
related organ system
– 2-4 body areas/organ systems
•
Detailed
– Extended exam of affected body area(s) and other symptomatic or
related organ systems
– 5-7 body areas /organ systems
•
Comprehensive
– Complete single system specialty exam or
– Complete multi-system exam
– 8 or more body areas/organ systems
Medical Decision Making
 Number
options
of possible diagnoses and/or management
 Amount
and/or complexity of medical records,
diagnostic tests, and/or other information that must
be reviewed
 Risk
of complications, morbidity and/or mortality,
associated with the patient’s presenting problem.
Includes need for diagnostic procedures and
management options
Medical Decision Making
Decision
Making
Number of
Diagnoses
Amount of
Data
Risk of
Complication
Straight
forward
Minimal
Min. or None
Minimal
Low
Complexity
Moderate
Complexity
Limited
Limited
Low
Multiple
Moderate
Moderate
High
Complexity
Extensive
Extensive
High
Time Reporting: CPT Counseling Rule
 Use
when the time spent in ‘counseling and
coordination of care’ > 50% of the E&M visit
 The 3 key components of history, PE, MDM may
be ignored
– Only time is used to select the level of care
A
summary of the ‘counseling’ discussion should be
included with the note
 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
Preventive Medicine Services
 E/M
services performed in the absence of a
significant problem/abnormality
 Extent
age
and focus depends on the patient’s
 Included
counseling/anticipatory
guidance/risk factor reduction
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/2003 Medicare
–
–

99381 Age< 1 year
99382 Ages 1-4 years
2.75/$101.16
2.96/$108.89
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 year
99392 Ages 1-4 years
2.08/$76.51
2.33/$85.71
Office Visits-New Patient
Codes
99201
99202
99203
99204
99205
History
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive Comprehensive
Exam
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive Comprehensive
Decision
Making
Straight
Forward
Straight
Forward
Low
Moderate
Complex Complex
High Complex
Time FF
10
20
30
45
60
Key #
3 of 3
3 of 3
3 of 3
3 of 3
3 of 3
Office Visits-Established Patient
Codes
99211
99212
99213
99214
99215
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
5
10
15
25
40
Key #
2 of 3
2 of 3
2 of 3
2 of 3
2 of 3
Consultations
 Consultation
is a service provided by a physician whose
opinion or advice is requested by another physician or
other appropriate source
 Consultant
may initiate diagnostic and/or therapeutic
services
 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
Office Consultation/ New or Est
Code
99241
99242
History
Problem
Focused
Exam
Problem
Focused
99243
99244
99245
Expanded Detailed
Problem
Focused
Comprehensive
Comprehen.
Expanded Detailed
Problem
Focused
Comprehensive
Comprehen.
Decision StraightMaking forward
Straightforward
Low
Mod Complex
Complex
High
Complex
Time FF 15
3 of 3
Key #
30
40
60
80
3 of 3
3 of 3
3 of 3
3 of 3
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 services,
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
Outpatient
Face to Face
99354 first 30-74 min
Face to Face
99355 each add 30 min
>75
Before or after Face to 99358 first 30-74 min
Face
of non-face to face
Before or after Face to 99359 each add 30 min
Face
>75 min
Modifiers
 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

Used to report developmental screening with E/M code
-32 Mandated Services
-52 Reduced Services