coding 101: getting paid for what you do jeannine z. p. engel, md assistant professor of medicine...

Coding 101:Getting Paid for What You Do

Jeannine Z. P. Engel, MDAssistant Professor of Medicine

Vanderbilt University Medical Center

Background

HCFA, now CMS (Center for Medicare and Medicaid Services) issued guidelines for documentation of different service codes in 1995. They were revised in 1997. Either can be used.

In general, the 1995 guidelines are more favorable for General Internists.

This presentation will focus on 1995 guidelines.

Why should we care? Individual Benefits

•Thought vs. Action: General IM reimbursement traditionally lower than procedure-based specialties

•Getting paid for what we do - reimbursement for practice groups and individuals can increase

•“Playing the game” vs. “Changing the game”

Disclaimer

This presentation will provide basic information regarding documentation and coding. Before applying this information at your institution or practice site, YOU MUST CHECK WITH YOUR COMPLIANCE OFFICE or LOCAL MEDICARE CARRIER to be sure these general principles are appropriate for your practice situation.

Learning Objectives Review documentation requirements

for basic outpatient office visits, including Annual Exams

Learn efficient documentation of Medical Decision Making

Discuss appropriate use of Office Consultation by General Internist

Gain comfort in coding levels 3, 4, 5 return office visits

Basic CodingRules and Regulations

New vs. Return

A new patient has not received professional services from you or a member of your group in any service location (e.g. hospital) in the past 3 years

Multi-specialty groups: variable

If established patient has not been seen in 3 years, bill them as New

Elements for E&M visits History

• Chief Complaint (CC)• History of Present Illness (HPI)• Review of Systems (ROS)• Past, family, and social history (PFSH)

Exam• Number of organ systems (1995

guidelines) Medical Decision Making (MDM)

• # diagnoses or management options• Amount of data/complexity• Risk level to patient

New Patient- outpatient visit3/3 needed

CPT 99201 99202 99203 99204 99205HPI

ROS

PFSH

1 1

1

4

2

1

4

10

3

4

10

3

Exam 1 2 5 8 8

MDM Straight-forward

Straight-forward

Low Moderate

High

Time

(min)

10 20 30 45 60

New Outpatient Visit

Need 3 of 3

99201 99202

99203

99204 99205

History (need all) HPI ROS PFSH

1 11

421

4103

4103

Exam 1 2 5 8 8

MDM (2/3) #Dx Data Risk

10No meds

10No meds

221 stable prob

1new no w/uor 3 stable 3Prescription medOr 2 stable pr.

1new w W/U or 2 worse4Life threaten

Time if counseling is >50%

10 min 20 30 45 60


• Chief Complaint

• History of Present Illness (7)

Location

Quality

Severity

Duration

Timing

Modifying Factors

Associated signs and symptoms


• Chief Complaint

• History of Present Illness

• Review of Systems (14) Constitutional-fever/wt

Eyes

Ears/nose/mouth/throat

CV

Respiratory

GI

GU

Musculoskeletal

Skin

Neurologic

Psychiatric

Endocrine

Heme/lymphatic

Allergic/immunologic


• Chief Complaint

• History of Present Illness

• Review of Systems

• Past, Family, and Social History

−Past Medical History

−Family history

−Social history

Pearls for documenting History

Can refer to previously documented elements: “Problem list updated as part of today’s visit”

“All other systems reviewed and negative” may be used in most cases to document negatives.

Taking history from someone other than the patient increases level of medical decision making.

Single bullets satisfy PFSH requirements - does not need to be exhaustive


Exam

• # of organ systems (12) Constitutional-VS,

general appearance Eyes Ears, nose, mouth,

throat Cardiovascular (inc

edema) Respiratory GI

GU Musculoskeletal Skin Neurologic Psychiatric Heme/lymph/

immuno-logic

Physical Exam

How many organ systems can you document before you lay a stethoscope on your patient??

Physical Exam SEVEN!!

• General appearance

• Eyes - sclera anicteric/injected

• HENT - hearing intact (hard of hearing)

• MSK - normal gait/limping

• Psych - normal (depressed/flat) affect

• Skin - no rash on face, arms

• Immunologic - NKDA (use for PMH or PE)

Coding New Patient Visits

Need 3 of 3 elements documented (history, exam, decision making)

MDM and MEDICAL NECESSITY SHOULD DRIVE CODING

MDM and MEDICAL NECESSITY SHOULD

DRIVE CODING

Coding Return Patient Visits Only need 2 of 3 elements

documented to meet level of service coded (History, PE, MDM)

MDM and MEDICAL NECESSITY STILL DRIVE CODING

Return Patient- outpatient visit2/3 needed

CPT 99211 99212 99213 99214 99215HPI

ROS

PFSH Non-physician visit

1-3

None

None

1-3

1

none

4+

2-9

1

4+

10+

2

Exam

1 system

2-4 systems

5-7 systems

8+ systems

MDM

Straight-forward

Low Moderate

High

Time

10 min 15 min 25 min 40 min

Return Outpatient Visit

Element(Need 2 of 3)

99212 99213 99214 99215

History HPI ROS PFSH

1 11

4 (or 3 chronic)21

4 (or 3 chronic)10 (“o/w neg”)2

Exam (# systems)

0 2 5 8

Complexity(need 2 of 3)

Dx Data

Risk

1 prob

0

No meds

2 est prob-stable or1 est prob-worse2

1 stable prob

3 stable est prob or1 new, no w/u

3Prescriptn med or 2 stable prob

2 prob-worse or 1 new, w/u 4Severe side effects, DNR

Time if counseling is >50%

10 min 20 30 45

DocumentingMedical Decision

MakingThe Real Meat of Internal

Medicine

Medical Decision Making

Diagnoses

Data

Risk

Medical Decision Making Number of diagnoses

• Number and type of presenting problems

Amount/complexity of data reviewed• Ordering tests and reviewing of tests

• Obtaining records or history from others

Overall risk of complications to patient before seeing another medical professional• See “Table of Risk”

Number of Diagnoses Self-limited or minor: 1 point each (2 max)

Established problem, stable: 1 point

Established problem, worsening: 2 points

New problem, no addt’l workup: 3 points

New problem, with further workup: 4 points

Complexity (and thus level of service)

• Straight-forward=1; Low=2, Moderate=3, High=4

Amount and Complexity of Data Review and/or order of clinical test: 1 point

• Basically all labs

Review and/or order of radiology: 1 point Review and/or order of medical test: 1 point

• Includes vaccines, ECG, echo, PFTs

Discussion of test with performing MD: 1 point

Independent review of test: 2 points Old records or hx from another person

• Decision to do this: 1 point

• Doing it and summarizing: 2 points

Overall Risk Table

Learn and Love the overall risk table

3 categories: presenting problem, dx procedures, management options

Highest level of risk in ANY of the 3 categories is the overall risk level for that patient

Overall Risk Table

Pearls:

•Prescription drug management: moderate

•2+ stable chronic illnesses: moderate

•Abrupt mental status change: high

•1 chronic illness w/ severe exacerbation: high

Overall Decision Making TableNeed 2 of 3 elements to qualify for given levelType of MDM

Straight-forward99201/02

99212

Low9920399213

Moderate9920499214

High9920599215

# dx 1 2 3 4+

Amt data

0 or 1 2 3 4+

Overall Risk

minimal low moderate high

Counseling, Annual Exams

and Office Consultation

Counseling When time spent counseling >50% of total

visit, then TIME becomes the deciding factor for coding

Total billing physician face to face time

• 99213: 15 min

• 99214: 25 min

• 99215: 40 min

Must document time spent and reason for counseling

Counseling is:• “A discussion with the patient and/or family

concerning one or more of the following areas” CPT book

• Recommended tests, diagnostic results, impressions

• Prognosis• Risks/benefits of treatment (management)

options• Instructions for treatment (management) options

and follow up• Importance of compliance with treatment

(management) options• Risk factor reduction• Patient and family education

Preventative Service Visits NO Chief complaint or HPI

MUST HAVE• Comprehensive ROS (10 organ systems)• Comprehensive or interval PFSH• Comprehensive assessment of risk factors

appropriate to age• Multi-system physical exam appropriate to

age and risk factors (RF)• Assessment/Plan which includes

counseling, anticipatory guidance and RF reduction

Preventative Service Visits

New vs. Return rules are the same

Coding based on age of patient

NO specific guidelines for what to include with each age group

Documentation of anticipatory guidance/risk factor reduction is the common missing element

Can refer to previous ROS, PMH, FH, etc.

Outpatient Consultation

Consultations require:

•A request from another provider•The provision of a consultation evaluation

service•A report of the service to the requesting

provider

Simply put, one provider asks a question, and the consultant answers it.

Consultation Requirements

New CMS requirements as of Jan 2006:

The written request for a consultation must be included in the requesting provider’s plan of care.

A consultation request may be written on an order form in a shared medical record.

The consultant must also document the reason for the consultation.

The “Question” must be documented in 2 medical records

Consultation Requirements

The written report may be part of a common medical record or in a separate letter to the requesting provider and must be readily available.

The written report must include the findings and recommendations (the “answer” to the original provider’s question.)

The consultant is expected to have expertise beyond that of the requesting provider.

Coding Outpatient Consultations CPT codes 99241-99245

Documentation requirements are identical to New Patient visit codes

Outpatient Consult F/U codes were deleted in Jan 2006

Pre-Operative Consultations

This is the most common scenario for a General Internist

You CAN bill Consultation on an established patient, as long as all the criteria are met

CMS rules state: “a pre-operative consultation at the request of a surgeon is payable if the service is medically necessary and not routine screening.”

Pre-Operative Consultations Following a pre-operative consultation,

if the same MD/NPP assumes responsibility for management of all or part of the patient’s care postoperatively, the subsequent visit codes must be used.

• Example – IM performs preop consult for patient prior to surgery; surgery occurs and surgeon requests IM inpatient MD to provide post operative care, in this scenario the inpatient IM MD cannot bill a second consult.

Second Opinions - Outpatient

For 2nd opinion evaluations in the outpatient or office setting, report the appropriate Office or other outpatient codes (new or established patient) for the level of service performed.

Confirmatory Consultation codes were deleted in Jan 2006

Consults Within a Group

Payment will continue to be made for a consultation if a provider in a group practice requests a consultation from another MD in the same group practice when the consulting MD has expertise in a specific medical area beyond the requesting professional’s knowledge.

You have the Basics

Let’s apply them to some real cases!

Case #1

CC: 55 yo woman (known to you) presents with back pain

Level 3, 4, or 5?

Depends on:•medical necessity•what is done•what is documented

Case #1

CC: 55 yo woman (known to you) presents with back pain

HPI• Patient awoke 1 week ago with constant,

sharp, moderately-severe LBP assoc w/ intermittent spasms. Improves w/ ibuprophen. Remote history of similar sx. No trauma, fevers, weakness, bowel or bladder sx.

Case #1 (cont’d)

Exam • Gen: BP 110/60 • Back: lumbar paraspinous tenderness

Assessment• LBP, probably muscular

Plan• Continue ibuprofen• Begin cyclobenzaprine 10mg TID prn• Return in 2 weeks if not better, sooner

prn

Outpatient Established PatientElement

(need 2 of 3)99211

99212 99213 99214 99215


Min. prob. may

1 11

4 (or 3 chronic)21

4 (or 3 chronic)102

Exam* # systems

not 0 2 5 8

Complexity (2/3) Dx Data Risk

needMD

10No meds

221 stable prob

3 (1 new no w/u)3Prescription medOr 2 stable pr.

4 (1 new w/ W/U)4Life threaten

Time (≥50%counsel’g)

5 10 15 25 40Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)

*Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215)

Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4

Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2


(need 2 of 3)99211

99212 99213 99214 99215


Min. prob. may

1 11

4 (or 3 chronic)21

4 (or 3 chronic)102

Exam* # systems

not 0 2 5 8


needMD 1

0No meds

221 stable prob

3 3Prescription medOr 2 stable pr.



5 10 15 25 40Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)

*Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215)



Case #1 - Modification AMore Documentation

Add reference to PFSH (PMH, FH, or SH)

• “Problem list and medications reviewed, see summary page” OR

• 50 yo woman with HTN OR

• 50 yo non-smoker OR

• Patient with NKDA OR

• Meds-Premarin

Outpatient Established Patient

Element(need 2 of 3)

99211

99212 99213 99214 99215


Min. prob. may

1 11

4 (or 3 chronic)21

4 (or 3 chronic)102

Exam # systems

not 0 2 5 (or Detailed)

8


needMD 1

0No meds

221 stable prob




5 10 15 25 40

Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)

Exam: Check with compliance or local Medicare intermediary for their rules re: detailed



Case #1 - Modification BMore Complexity

Now consider if the patient has a T:102.1 Additional history:

• PFSH: “non-smoker”

• ROS: “complete 10 organ ROS o/w negative”

No change in exam Additional workup:

• Will order CBC, urgent MRI lumbar spine, discuss with spine surgeon

• “Concern for epidural abscess”


(need 2 of 3)99211

99212 99213 99214 99215


Min. prob. may

1 11

4 (or 3 chronic)21

4 (or 3 chronic)102

Exam # systems not 0 2 5 8


needMD 1

0No meds

221 stable prob


44Life threaten


5 10 15 25 40Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)

Exam: Check with compliance or local Medicare intermediary for their rules re: detailed



Case #2 60 yo male presents for 3 month f/u visit

for HTN, AODM. Also reports mild fatigue and some leg cramps, occurring 2-3 times per week. BP better since addition of HCTZ at last visit. Sugars running <160. Pt denies CP, SOB, LE edema.

Meds updated in problem list PE: BP:138/80 HR:75 RR:16 Gen: looks well CV: RRR, no m,r,g Lungs: Clear Ext: no edema, no calf tenderness to

palpation

Case #2 (cont’d)

A/P: 1. HTN, well controlled, continue same meds

2. AODM, well controlled, continue meds/diet, exercise, check HgA1c

3. Leg cramps- possible low K, check BMP, Mg.

F/U in 3 months

Case #2 (cont’d) 60 yo male presents for 3 month f/u visit for HTN,

AODM. Also reports mild fatigue and some leg cramps, occurring 2-3 times per week. BP better since addition of HCTZ at last visit. Sugars running < 160. Pt denies CP, SOB, LE edema. 2 chronic problems, stable and 1 new; 5 HPI 3ROS

Meds updated in problem list 1 PFSH level 4 Hx PE: BP:138/80 HR:75 RR:16 Gen: looks well CV: RRR, no m, r, g Lungs: Clear 4PE level 3 Exam Ext: no edema, no calf tenderness to palpation

Case #2 (cont’d) A/P: 1. HTN, well controlled, continue

same meds

2. AODM, well controlled, continue meds/diet, exercise, check HgA1c

3. Leg cramps, fatigue - possible low K, check BMP, Mg. F/U in 3 months

Moderate MDM: diagnoses-high; data-low; risk- moderate

99214 (count History and MDM)

Final thoughts

The coding rules initially appear complex but can be mastered.

It takes some practice.

Use these tools to “self-audit.”

It is your responsibility to select the right code for the work that you do.

coding 101: getting paid for what you do jeannine z. p. engel, md assistant professor of medicine...

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