Coding 101Coding 101
Taken from “Beginning Coding”, “Intermediate Coding”, and “I Hate Coding” by Dianne Demers
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Ice BreakerIce Breaker
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Coding and DocumentationCoding and DocumentationObjectives:Objectives:
The Participant will be able to The Participant will be able to
● Define Define CPT, ICD 9, and DSM 4 CodingCPT, ICD 9, and DSM 4 Coding● ExplainExplain the reasons why appropriate coding the reasons why appropriate coding
and documentation is so important in SBHC and documentation is so important in SBHC settings. settings.
● DemonstrateDemonstrate correct use of CPT and ICD 9 correct use of CPT and ICD 9 codescodes
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Coding Background and Coding Background and TerminologyTerminology
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Coding DefinitionCoding Definition
Coding is an alphanumeric system used to Coding is an alphanumeric system used to translate medical procedures and services translate medical procedures and services into datainto data
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Types of Coding Types of Coding
Current Procedural Terminology (CPT)Current Procedural Terminology (CPT) International Classification of Diseases International Classification of Diseases
(ICD-9 Clinical Modification - CM)(ICD-9 Clinical Modification - CM) Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental
Disorders (DSM IV-TR)Disorders (DSM IV-TR)
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Coding Is Not The Coding Is Not The Same As BillingSame As Billing
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Coding is Medicare DriveCoding is Medicare Drive
Pediatrics was not considered in Pediatrics was not considered in original coding guidelines, so some of original coding guidelines, so some of the things we do in SBHCs may not fit the things we do in SBHCs may not fit wellwell
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SBHC CodingSBHC Coding
There is no difference between coding There is no difference between coding in a SBHC and any other setting – the in a SBHC and any other setting – the coding assumptions are the same.coding assumptions are the same.
You provide the same level of care You provide the same level of care regardless of the location.regardless of the location.
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Why Code Correctly?Why Code Correctly?
●Reimbursement depends on it.Reimbursement depends on it.●Codes describe the services you Codes describe the services you
provideprovide●Codes justify these servicesCodes justify these services● Services not documented “never Services not documented “never
happened”happened”
PS: Never code for the purpose of PS: Never code for the purpose of getting more money getting more money
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The Coding Process has 2 PartsThe Coding Process has 2 Parts
1.1. “What you did” = CPT “What you did” = CPT
2.2. “Why you did it” = ICD-9 or DSM-4 TR “Why you did it” = ICD-9 or DSM-4 TR
YOU MUST ALWAYS USE BOTHYOU MUST ALWAYS USE BOTH
a what and a whya what and a why
(NO EXCEPTIONS)(NO EXCEPTIONS)
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When a provider is under-When a provider is under-coding they tell the wrong storycoding they tell the wrong story
This wrong story is:This wrong story is: SBHC Providers are seeing very few SBHC Providers are seeing very few
patients with multiple problems.patients with multiple problems. SBHC Providers should see more SBHC Providers should see more
patients since they are not seeing patients since they are not seeing complicated patients.complicated patients.
The SBHC should decrease the The SBHC should decrease the number of physicians and add more number of physicians and add more mid-level providers.mid-level providers.
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There Are Two Coding There Are Two Coding Guidelines - 1995 & 1997Guidelines - 1995 & 1997 Both 1995 and 1997 guidelines are Both 1995 and 1997 guidelines are
approved for use by CMSapproved for use by CMS Agencies may specify use of 1995 or Agencies may specify use of 1995 or
1997 guidelines1997 guidelines 1997 guidelines are more specific than 1997 guidelines are more specific than
1995 in the examination portion (they 1995 in the examination portion (they are more computer friendly)are more computer friendly)
New guidelines have been proposed, New guidelines have been proposed, but have not yet been acceptedbut have not yet been accepted
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Coding Guidelines Coding Guidelines 1995 vs. 19971995 vs. 1997
This lecture is based on the 1995 This lecture is based on the 1995 guidelines because they are 15 pages guidelines because they are 15 pages long vs. 57 pages of the 1997 version.long vs. 57 pages of the 1997 version.
www.cms.hhs.gov/MLNProducts/www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdfDownloads/1995dg.pdf
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FraudFraud
IntentionalIntentional deception or deception or misrepresentationmisrepresentation● Deliberately billing for services not Deliberately billing for services not
performedperformed● Unbundling of servicesUnbundling of services● Intentionally submitting duplicate claimsIntentionally submitting duplicate claims
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AbuseAbuse
Improper billing practicesImproper billing practices● Billing for non-covered servicesBilling for non-covered services● Misusing codes on a claim formMisusing codes on a claim form
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ErrorsErrors
Accept it, you will Accept it, you will make them.make them.
Your best defense Your best defense is having a plan for is having a plan for your coding and your coding and being able to being able to explain it.explain it.
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Coding Does Not Coding Does Not Equal Good Equal Good
MedicineMedicine
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But - Coding is Good But - Coding is Good DocumentationDocumentation
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CPT Codes document:CPT Codes document:
Level of ServiceLevel of Service
Procedures ProvidedProcedures Provided
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Examples of CPT codesExamples of CPT codes
Evaluation Evaluation & &
Management Management 9921199211
9921299212 9921399213 9921499214 9921599215
Preventive Health99391993929939399394993959939799397
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ICD-9 Codes document:ICD-9 Codes document:
The The reason reason behind the visitbehind the visit
(They must support the CPT codes)(They must support the CPT codes)
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General Coding PrinciplesGeneral Coding Principles
Coding gets you paid for your servicesCoding gets you paid for your servicesCoding can be used to justify the need Coding can be used to justify the need
for services to your fundersfor services to your funders
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Coding with ICD-9Coding with ICD-9 ICD-9 codes have 3, 4 or 5 digitsICD-9 codes have 3, 4 or 5 digits● The greater the number of digits, the The greater the number of digits, the
higher the specificityhigher the specificity●Use a 5-digit code when it existsUse a 5-digit code when it exists●Use a 4-digit code only if there is no 5-Use a 4-digit code only if there is no 5-
digit code with the same categorydigit code with the same category●Use a 3-digit code only if there is no 4-Use a 3-digit code only if there is no 4-
digit code within the same categorydigit code within the same category
PS: Omitting the required 4PS: Omitting the required 4thth or 5 or 5thth digit will digit will result in the denial of a claim. Do not add any result in the denial of a claim. Do not add any additional digits, even zeroadditional digits, even zero
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ICD-9-CM CodesICD-9-CM Codes
Range from 001.0 to V82.9Range from 001.0 to V82.9They identify:They identify:● DiagnosesDiagnoses● SymptomsSymptoms● ConditionsConditions● ProblemsProblems● ComplaintsComplaints● Other reason for the procedure, service, or Other reason for the procedure, service, or
supply providedsupply provided
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ICD-9-CM CodesICD-9-CM Codes Three volumesThree volumes● Volume 1 Tabular List of DiseasesVolume 1 Tabular List of Diseases
●Notes all exclusive terms and 5Notes all exclusive terms and 5 thth-digit -digit instructionsinstructions
● Volume 2 Alphabetic Index of DiseasesVolume 2 Alphabetic Index of Diseases●Does not contain detail – Do Not code Does not contain detail – Do Not code
from this volumefrom this volume● Volume 3 ProceduresVolume 3 Procedures
●Used almost exclusively for hospital Used almost exclusively for hospital servicesservices
PS: (All 3 Volumes are generally found in one binding)PS: (All 3 Volumes are generally found in one binding)
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““V” CodesV” Codes For circumstances other than disease or injuryFor circumstances other than disease or injury Three categories:Three categories:● Problem Problem – Could affect overall health – Could affect overall health
status, but is not a current illness or injurystatus, but is not a current illness or injury● Ex.: V14.2 Personal history of allergy to Ex.: V14.2 Personal history of allergy to
sulfonaminessulfonamines● ServiceService – Circumstances other than illness – Circumstances other than illness
or injuryor injury● Ex.: V68.1 Issue of a repeat prescriptionEx.: V68.1 Issue of a repeat prescription
● Factual Factual – Certain facts that do not fall into – Certain facts that do not fall into the “problem” or “service” categoriesthe “problem” or “service” categories
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““V” CodesV” Codes
Can be used as a:Can be used as a:● Solo CodeSolo Code● Principal codePrincipal code● Secondary codeSecondary code
May represent check-ups, screenings, May represent check-ups, screenings, administrative requests, prescription administrative requests, prescription refillsrefills
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Rules for CodingRules for Coding Outpatient Visits Outpatient Visits
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Determine Type of Office Visit Determine Type of Office Visit Evaluation and ManagementEvaluation and Management
New Patients vs. Established PatientsNew Patients vs. Established Patients
Preventive Health VisitsPreventive Health Visits New Patients vs. Established PatientsNew Patients vs. Established Patients
Counseling VisitsCounseling Visits Medical Visit – talker onlyMedical Visit – talker only
Mental Health VisitsMental Health VisitsNew Patients vs. Established PatientsNew Patients vs. Established Patients
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Determine Medical NecessityDetermine Medical Necessity
Services are reasonable and Services are reasonable and necessary for the diagnosis and necessary for the diagnosis and treatment of illness or injury.treatment of illness or injury.
All payors define necessity differentlyAll payors define necessity differentlyClinical rationale must be documented Clinical rationale must be documented
through coding.through coding.You cannot write more, to get paid You cannot write more, to get paid
more.more.
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Determine Chief ComplaintDetermine Chief Complaint
The reason for the patient’s visitThe reason for the patient’s visit● S of a SOAP noteS of a SOAP note
Codes used must relate to chief Codes used must relate to chief complaint or they are invalidcomplaint or they are invalid
And, the chief complaint must be And, the chief complaint must be documented in the chartdocumented in the chart
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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services
Used for acute care visitsUsed for acute care visitsFive levels of serviceFive levels of serviceSeven components within the levelsSeven components within the levels● Key components – history, exam and Key components – history, exam and
medical decision makingmedical decision making● Contributory components – counseling, Contributory components – counseling,
coordination of care, nature of presenting coordination of care, nature of presenting problem, and timeproblem, and time
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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services
Beginning information about coding Beginning information about coding deals with the three key components:deals with the three key components:● HistoryHistory● ExaminationExamination● Medical Decision MakingMedical Decision Making
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Evaluation/Management Evaluation/Management (E / M) Services(E / M) Services
There are 5 Levels of serviceThere are 5 Levels of service1.1. MinimalMinimal
2.2. Self-Limited or MinorSelf-Limited or Minor
3.3. Low SeverityLow Severity
4.4. Moderate SeverityModerate Severity
5.5. High SeverityHigh Severity
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CPT Codes Used for E/M VisitsCPT Codes Used for E/M Visits
New PatientsNew Patients
Level 1 99201Level 1 99201Level 2 99202Level 2 99202Level 3 99203Level 3 99203Level 4 99204Level 4 99204Level 5 99205Level 5 99205
Established PatientsEstablished Patients
9921199211 9921299212 9921399213 9921499214 9921599215
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Coding StepsCoding Steps
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Coding StepsCoding Steps
First StepFirst Step - - Determine if your patient is: Determine if your patient is:
A New Patient A New Patient or or
An Established PatientAn Established Patient
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Definition of a new patient:Definition of a new patient:
It is the patient’s first visit to the providerIt is the patient’s first visit to the providerThe patient has not received any The patient has not received any
professional services from the provider professional services from the provider or another provider of the same specialty or another provider of the same specialty who belongs to the same group practice, who belongs to the same group practice, within the past three years.within the past three years.
PS: Any time a patient is seen in an PS: Any time a patient is seen in an Emergency Room they are considered a Emergency Room they are considered a new patientnew patient
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If your patient does not If your patient does not meet the definition of a meet the definition of a
New PatientNew Patient, , then they are an then they are an
Established PatientEstablished Patient
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Coding StepsCoding StepsSecond Step - Second Step - determine the level of determine the level of
service for the visit, service for the visit,
To do this you need to determine the level of To do this you need to determine the level of service for each key component separatelyservice for each key component separately
There are 3 key componentsThere are 3 key components
They are:They are:1. History (HPI, ROS, PFSH)1. History (HPI, ROS, PFSH)2. Examination2. Examination3. Medical Decision Making3. Medical Decision Making
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Coding StepsCoding Steps
New PatientsNew PatientsWithin the 3 key components, there are Within the 3 key components, there are
5 levels of service5 levels of serviceRemember to Consider the Key Remember to Consider the Key
Components separately:Components separately:● HPI, ROS, PFSHHPI, ROS, PFSH● ExaminationExamination● Medical Decision MakingMedical Decision Making
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Example - New PatientExample - New PatientThe Level of Service for a new patient visit is The Level of Service for a new patient visit is determined by the lowest level of service (1 determined by the lowest level of service (1
through 5) of the three key componentsthrough 5) of the three key components
HPI, ROS, PFSH 4
Examination 4
Medical Decision Making
3This is the lowest level
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Coding StepsCoding Steps
Established PatientsEstablished PatientsAgain Consider the Key Components Again Consider the Key Components
Separately:Separately:● HPI, ROS, PFSHHPI, ROS, PFSH● ExaminationExamination● Medical Decision MakingMedical Decision Making
The level of service (1 – 5) is The level of service (1 – 5) is determined by the level that appears in determined by the level that appears in 2 of the three components, or by the 2 of the three components, or by the middle level middle level
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Example – Established PatientExample – Established Patient
HPI, ROS, PFSH
3This is the middle level
EXAM 2
Medical Decision Making 4
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Why is this?Why is this?
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Answer . . . Answer . . . There has to be a There has to be a
system, and this is what system, and this is what AMA came up with.AMA came up with.
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How to Steps of CodingHow to Steps of Coding
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How to Steps of Coding: How to Steps of Coding: Determine Level of Medical Decision MakingDetermine Level of Medical Decision Making
Determine Level of History ComponentDetermine Level of History ComponentDetermine Level of Physical ExaminationDetermine Level of Physical Examination
(You will need to reference the chart – examination notes for this)(You will need to reference the chart – examination notes for this)
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Determine Level of Medical Determine Level of Medical Decision MakingDecision Making
Medical Decision Making consists of Medical Decision Making consists of three sections:three sections:● Diagnosis or Management ProblemsDiagnosis or Management Problems● Diagnostic ProceduresDiagnostic Procedures● Treatment of Management OptionsTreatment of Management Options
Level is determined by the level found Level is determined by the level found in two of the three categories – or the in two of the three categories – or the middle number if all three are differentmiddle number if all three are different
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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section I: Section I: Diagnosis or Management of ProblemsDiagnosis or Management of Problems
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215One self-limited or minor problem
Two or more self-limited or minor problemsOne stable chronic conditionAcute uncomplicated illness
One or more chronic illnesses with complications
Two or more stable chronic conditionsUndiagnosed new problem w/uncertain prognoses
Acute illness with systemic symptomsAcute complicated injury
One or more chronic illness with severe complicationsAcute or chronic illness or injury that is life or limb threateningAbrupt change in neurologic status
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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section II: Diagnostic ProceduresSection II: Diagnostic Procedures
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
LabX-rayEKGUAUltrasound, etc.VenipunctureKOH
Physiologic tests not under stressPulmonary FunctionBarium EnemaArterial punctureSkin biopsies
Physiologic tests under stress-cardiac stress testsDiagnostic endoscopies with no risk factorsDeep needle or incisional biopsyObtained fluid from bodyCardiovascular imaging with contrast
Cardiovascular imaging with contrastInvasive diagnostic testsCardiac Electrophysiological tests Diagnostic endoscopies with identified risk factorsDiscography
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Determine Level of Medical Decision Making Determine Level of Medical Decision Making Section III: Section III: Treatment or Management OptionsTreatment or Management Options
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
RestGarglesElastic bandagesDressings
OTCsMinor surgeryPTOTIVs without additives
Minor surgery with risk factorsElective major surgery—no risk factors
Prescription drug managementIV fluids with additivesClosed facture or dislocation treatment w/o manipulationTherapeutic nuclear medicine
Elective Surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug treatment requiring intensive monitoringDecision not to resuscitate or de-escalate care because of poor prognosis
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How to Steps of Coding: How to Steps of Coding: Determine Level of History Component Determine Level of History Component
History component consists of three History component consists of three sections:sections:● History of Present Illness (HPI)History of Present Illness (HPI)● Review of Systems (ROS)Review of Systems (ROS)● Patient, Family, and Social History (PFSH)Patient, Family, and Social History (PFSH)
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Determine Level of History ComponentDetermine Level of History Component
Section I: History of Present IllnessSection I: History of Present Illness LocationLocation QualityQuality SeveritySeverity DurationDuration TimingTiming ContextContext Modifying factorsModifying factors Associated signs and symptomsAssociated signs and symptoms
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Determine Level of History ComponentDetermine Level of History Component
Section II: Review of SystemsSection II: Review of Systems Constitutional symptoms (fever, wt loss, etc.)Constitutional symptoms (fever, wt loss, etc.) EyesEyes Ears, nose, mouth, throatEars, nose, mouth, throat CardiovascularCardiovascular RespiratoryRespiratory GastrointestinalGastrointestinal GenitourinaryGenitourinary MusculoskeletalMusculoskeletal Integumentary (skin and/or breast)Integumentary (skin and/or breast) NeurologicNeurologic PsychiatricPsychiatric EndocrineEndocrine Hematologic/lymphaticHematologic/lymphatic Allergic/immunologicAllergic/immunologic
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Determine Level of History ComponentDetermine Level of History Component Section III: Patient, Family and Social HistorySection III: Patient, Family and Social History
Past medical historyPast medical history● Medication allergiesMedication allergies
Patient’s family historyPatient’s family history Patient’s social historyPatient’s social history● Age-appropriate review of past and Age-appropriate review of past and
current activitiescurrent activities● Tobacco usageTobacco usage
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History Component MatrixHistory Component Matrix(Number of components of each HPI, (Number of components of each HPI, ROS & PFSH required for each level)ROS & PFSH required for each level)
New 99201 99202 99203 99204 99205
Established 99211 99212 99213 99214 99215
HPI 0 1 1 4 4
ROS 0 0 1 2 10
PFSH 0 0 0 1 2
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How to of Coding Steps: How to of Coding Steps: Determine Level of Physical ExaminationDetermine Level of Physical Examination
ConstitutionalConstitutional EyesEyes Ears, Nose, Mouth, ThroatEars, Nose, Mouth, Throat CardiovascularCardiovascular RespiratoryRespiratory GastrointestinalGastrointestinal GenitourinaryGenitourinary MusculoskletalMusculoskletal SkinSkin NeurologicNeurologic PsychiatricPsychiatric Hematologic/Lympatic/ImmunologicHematologic/Lympatic/Immunologic
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Determine Level of Physical Examination:Determine Level of Physical Examination:# of body systems required for each level# of body systems required for each level
New 99201 99202 99203 99204 99205
Established 99211 99212 99213 99214 99215
Exam 0 1 4 5 8
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Coding Matrix Example:Coding Matrix Example:
New Patient Established Patient
History 3 3
Exam 2 2
Medical Decision Making
3 3
Level of Coding 2 3
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Coding Matrix Example:Coding Matrix Example:
New Patient Established Patient
History 4 4
Exam 2 2
Medical Decision Making
4 4
Level of Coding 2 4
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Coding ExerciseCoding Exercise
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Coding Exercise for Evaluation/ Coding Exercise for Evaluation/ Management ServicesManagement Services
Suzy Q is a 16 y/o female with c/o Suzy Q is a 16 y/o female with c/o severe “female” cramps - worse than usual.severe “female” cramps - worse than usual.She states she took Midol and it onlyShe states she took Midol and it onlyhelped a little. She is a new patient. helped a little. She is a new patient. Document on the exam and encounter Document on the exam and encounter form to a level 3, using audit sheet form to a level 3, using audit sheet as reference. as reference.
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How to Verify this is correct How to Verify this is correct level of documentation to level of documentation to
support level 3support level 3
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Count the componentsCount the components
HRI 1 - MidolHRI 1 - Midol
ROS 1 - crampsROS 1 - cramps
PFSH - 0PFSH - 0
______________________
Level 3Level 3
Exam 1-constExam 1-const
2-Abd2-Abd
3-back3-back
4-genito4-genito
________________________
Level 3Level 3
Med DecisionMed Decision
- acute/uncomp- acute/uncomp
- OTCs- OTCs
______________________
Level 3Level 3
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Preventive ServicesPreventive Services
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Preventive ServicesPreventive Services
These visits include a These visits include a comprehensive history and comprehensive history and examination, as well as appropriate examination, as well as appropriate counseling/anticipatory counseling/anticipatory guidance/risk factor reduction, guidance/risk factor reduction, interventions, and the ordering of interventions, and the ordering of age-appropriate age-appropriate laboratory/diagnostic procedures.laboratory/diagnostic procedures.
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Preventive ServicesPreventive Services
““Comprehensive” in a preventive Comprehensive” in a preventive service examination is not service examination is not synonymous with a “comprehensive” synonymous with a “comprehensive” E/M examination.E/M examination.
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Preventive Service CodesPreventive Service Codes
Age New Established< 1 99381 993911-4 99382 993925-11 99383 9939312-17 99384 9939418-39 99385 9939540-64 99387 9939765+ 99387 99397
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Preventive ServicesPreventive Services
Appropriate ICD-9 codes would be:Appropriate ICD-9 codes would be:
V20.2V20.2 for a for a Routine Infant or Child Health Routine Infant or Child Health CheckCheck
V70.3V70.3 for a for a Sports PhysicalSports Physical
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Preventive ServicesPreventive Services
Additional services provided at the time Additional services provided at the time of the visit should be reported with their of the visit should be reported with their specific CPT codes listed separately:specific CPT codes listed separately:● Examples:Examples:
● Snellen TestSnellen Test● LaboratoryLaboratory● ImmunizationsImmunizations● Administration of ImmunizationsAdministration of Immunizations
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Common Pitfalls inCommon Pitfalls inCodingCoding
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ICD-9 CM (ICD-9 CM (Clinical ModificationClinical Modification) ) Coding Guidelines Coding Guidelines
Order to list ICD-9 codesOrder to list ICD-9 codes
Coding Order is ImportantCoding Order is Important1.1. Acute Reason patient is being seen Acute Reason patient is being seen
needs to be listed first.needs to be listed first.2.2. Co-morbid diagnosis affecting treatment Co-morbid diagnosis affecting treatment
of principal diagnosis are listed next.of principal diagnosis are listed next.3.3. List all other documented conditions List all other documented conditions
coexisting at the time of the visit that coexisting at the time of the visit that require or affect patient care, treatment or require or affect patient care, treatment or management. Chronic diseases may be management. Chronic diseases may be listed as often as they are treatedlisted as often as they are treated
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ICD-9-CM Coding GuidelinesICD-9-CM Coding Guidelines
DO NOT CODE:DO NOT CODE:● Conditions previously treated that no Conditions previously treated that no
longer exist.longer exist.● Conditions that do not affect treatment Conditions that do not affect treatment
or management at the current visit.or management at the current visit.● Rule-out, suspected, questionable or Rule-out, suspected, questionable or
probable diagnoses.probable diagnoses.
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ICD-9-CM Coding Guidelines ICD-9-CM Coding Guidelines Review of Systems DocumentationReview of Systems Documentation
Cannot say “all other negative”Cannot say “all other negative”Must list pertinent and negative Must list pertinent and negative
findingsfindingsMust have a way to determine which Must have a way to determine which
systems were reviewedsystems were reviewedA check list is acceptableA check list is acceptable
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About Time With the PatientAbout Time With the Patient
Do not base your level of service on Do not base your level of service on time spent with patient.time spent with patient.
Time only comes into play if you are Time only comes into play if you are billing for counseling within an acute billing for counseling within an acute visit or if all you are doing is counselingvisit or if all you are doing is counseling
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Sports PhysicalsSports Physicals
They are not meant to be They are not meant to be comprehensive physicals – their focus comprehensive physicals – their focus is differentis different
Check www.aafp.org for an appropriate Check www.aafp.org for an appropriate formform
You can bill for a complete PE and a You can bill for a complete PE and a sports PE within the same yearsports PE within the same year
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Acute Problems within a Acute Problems within a Comprehensive PhysicalComprehensive Physical
When doing a preventive health visit When doing a preventive health visit (V20.2) and there is a separate health (V20.2) and there is a separate health acute problem – you can list both the acute problem – you can list both the preventive health visit code (first) and the preventive health visit code (first) and the acute visit code (second) – BUT THERE acute visit code (second) – BUT THERE MUST BE ICD-9 CODES THAT JUSTIFY MUST BE ICD-9 CODES THAT JUSTIFY BOTHBOTH
(the billing department must add a (the billing department must add a modifier)modifier)
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Be sure to know the Be sure to know the Reason for the VisitReason for the Visit
P re ve n tiveV is it
A cu teV is it
C o u n se lingV is it
R e a so n fo rV is it
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Late Effects of BurnsLate Effects of Burns
Late effects means the burn has healed. Late effects means the burn has healed. There should not be dressing changes.There should not be dressing changes.
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Counseling VisitsCounseling Visits
Counseling visits are when Counseling visits are when client comes in to discuss a client comes in to discuss a problem only. No hands are problem only. No hands are laid on the patient. laid on the patient.
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ExampleExampleDietary Surveillance & CounselingDietary Surveillance & Counseling
There must be a dietary problem in There must be a dietary problem in order to justify this code.order to justify this code.
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Be Specific with the Be Specific with the codes you usecodes you use
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784.1 Throat Pain784.1 Throat Pain
EXCLUDES:EXCLUDES:● Dysphagia 787.2Dysphagia 787.2● Neck pain 723.1Neck pain 723.1● Sore throat 462Sore throat 462● Chronic 472.1Chronic 472.1
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AGAIN - AboutAGAIN - AboutOver-coding and Under-codingOver-coding and Under-coding
CPT and ICD-9 codes must always CPT and ICD-9 codes must always relaterelate
The first ICD-9 code you use drives the The first ICD-9 code you use drives the relationship to the CPT coderelationship to the CPT code
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Poor example Poor example incorrect coding for incorrect coding for documentationdocumentation
See Handouts of Completed Note See Handouts of Completed Note Sample 10a Sample 10a (handout 9)(handout 9)
&&Encounter Form 10a Encounter Form 10a (handout 10)(handout 10)
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Analysis of incorrect coding Analysis of incorrect coding for documentationfor documentation
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Coding Audit Cheat Sheet Coding Audit Cheat Sheet Top half of formTop half of form
PATIENT IDENTIFIER____PATIENT IDENTIFIER____10a10aCODING AUDIT CHEAT SHEETCODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:TYPE OF SERVICE PROVIDED:Preventive Health – New patientPreventive Health – New patient ____________Preventive Health – Established patientPreventive Health – Established patient ____________Counseling Services– No Physical ComplaintCounseling Services– No Physical Complaint
Is time recorded in chart? Is time recorded in chart? YES _____YES _____NO _____NO _____Is a counseling code used? Is a counseling code used? YES _____ NO _____YES _____ NO _____
Evaluation / Management Visit: where counseling determines timeEvaluation / Management Visit: where counseling determines timeIs the total time of the visit recorded Is the total time of the visit recorded YES _____YES _____NO _____ NO _____ Is the time spent in counseling recorded Is the time spent in counseling recorded YES _____ NO _____YES _____ NO _____Is a counseling code used? Is a counseling code used? YES _____ NO _____YES _____ NO _____
Evaluation / Management Visit –Evaluation / Management Visit – NEW PATIENTNEW PATIENTEvaluation / Management Visit – ESTABLISHED PATIENTEvaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USEDCPT & ICD-9 CODES USED
CPT CODES: CPT CODES: 9920399203 ICDE-9 CODES: ICDE-9 CODES: 625.3625.3 DO THE CPT/ICD-9 CODESDO THE CPT/ICD-9 CODESCORRELATE?CORRELATE?
YES __YES __XX___NO ______ ___NO ______
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Coding Audit Cheat SheetCoding Audit Cheat SheetBottom Half of FormBottom Half of Form
HISTORY AND EXAMINATIONHISTORY AND EXAMINATION
New New 9920199201 9920299202 9920399203 9920499204 9920599205 EstablishedEstablished 9921199211 9921299212 9921399213 9921499214 9921599215
HPIHPI 00 11 11 44 44 ROSROS 00 00 11 22 1010 PFSHPFSH 00 00 00 11 22 EXAMEXAM 00 11 44 55 8 8
CHART AUDIT LEVELS FOR E/M VISITSCHART AUDIT LEVELS FOR E/M VISITS
HPI, ROS, PFSHHPI, ROS, PFSH 33 NEW PATIENT LEVELNEW PATIENT LEVEL 22
Lowest level supports levelLowest level supports level
EXAMINATIONEXAMINATION 22 ESTABLISHED PT LEVEL ____ESTABLISHED PT LEVEL ____
2 of 3 or middle level supports level2 of 3 or middle level supports level
MEDICAL DECISION MAKINGMEDICAL DECISION MAKING 33
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Medical Decision MakingMedical Decision Making Section I: Section I: Diagnosis or Management of ProblemsDiagnosis or Management of Problems
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215One self-limited or minor problem
Two or more self-limited or minor problems
-One stable chronic condition-Acute uncomplicated illness
One or more chronic illnesses with complicationsTwo or more stable chronic conditionsUndiagnosed new problem w/uncertain prognosesAcute illness with systemic symptomsAcute complicated injury
One or more chronic illness with severe complicationsAcute or chronic illness or injury that is life or limb threateningAbrupt change in neurologic status
99
Medical Decision Making Medical Decision Making Section II: Diagnostic ProceduresSection II: Diagnostic Procedures
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
LabX-rayEKGUAUltrasound, etc.VenipunctureKOH
Physiologic tests not under stressPulmonary FunctionBarium EnemaArterial punctureSkin biopsies
Physiologic tests under stress-cardiac stress testsDiagnostic endoscopies with no risk factorsDeep needle or incisional biopsyObtained fluid from bodyCardiovascular imaging with contrast
Cardiovascular imaging with contrastInvasive diagnostic testsCardiac Electrophysiological tests Diagnostic endoscopies with identified risk factorsDiscography
Other levels of Diagnostic procedures do not usually apply to SBHC, but you only Other levels of Diagnostic procedures do not usually apply to SBHC, but you only need to have 2 of the 3 areas of medical decision making to agree.need to have 2 of the 3 areas of medical decision making to agree.
100
Medical Decision Making Medical Decision Making Section III: Treatment or Management OptionsSection III: Treatment or Management Options
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
RestGarglesElastic bandagesDressings
OTCsMinor surgeryPTOTIVs without additives
Minor surgery with risk factorsElective major surgery—no risk factorsPrescription drug managementIV fluids with additivesClosed facture or dislocation treatment w/o manipulationTherapeutic nuclear medicine
Elective Surgery with identified risk factorsEmergency major surgeryParenteral controlled substancesDrug treatment requiring intensive monitoringDecision not to resuscitate or de-escalate care because of poor prognosis
101
Unfortunately – Because of this Unfortunately – Because of this documentation/coding error - you documentation/coding error - you
will not get paid for this visit.will not get paid for this visit.This is why it is very important to This is why it is very important to
verify that verify that charting supports charting supports
all levels of coding decision all levels of coding decision making.making.
102
Questions & AnswersQuestions & Answers