CPT Codingand Why You CareTed A. Bonebrake, M.D.

CPT Coding Current Procedural Terminology System of coding medical encounters

for billing purposes in the US First published by AMA in 1966 Updated annually on January 1

CPT Coding E & M Codes (Evaluation and

Management) Procedural Codes Pathology, Laboratory, Radiology

CPT CodingWhy do we care?1. Correct coding results in correct

reimbursement2. Coding errors can result in claim

rejection, rebilling and delayed reimbursement

3. Providers are responsible for errors4. Incorrect coding may result in charges

and fines

Reimbursement Most family

physicians today are employees of a clinic or hospital system

Part or all of physician compensation is based on production.

Reimbursement Salaries and/or bonuses are typically

based on production which is determined one of two ways: Gross receipts minus overhead RVU’s (Relative value units)

Either method is ultimately determined by the CPT codes that a provider bills for.

Incorrect Coding False Claims Act 1986 HIPAA 1996 The Office of Inspector General (OIG) and

the Department of Justice enforce federal, state, and local laws to control healthcare fraud and abuse

They conduct investigations and audits pertaining to the delivery of and payment for healthcare services.

Incorrect Coding In egregious cases, a

doctor can be fined, excluded from Medicare and Medicaid, lose their medical license, and even do jail time.

More commonly, the government imposes financial penalties.

Incorrect Coding The civil monetary penalty for

healthcare fraud has been increased from $2000 to $10,000 for each item or service for which fraudulent payment has been received.

The monetary assessment has been increased from not more than twice the amount to not more than three times the amount of the overpayment.

Incorrect Coding Two practices have been added to the

list of fraudulent activities for which civil monetary penalties may be assessed: 1. Engaging in a pattern of presenting claims based on a code that the person knows or should know will result in greater payments than appropriate.2. Submitting a claim or claims that the person knows or should know is for a medical item or service that is not medically necessary.

Audits and InvestigationsWhat will trigger an audit or investigation?

A pattern of “upcoding” Whistle blowers E & M codes that are

consistently different than average distributions for your specialty

Within a group setting, inconsistent coding among partners.

Audits and InvestigationsWhat will trigger an audit or investigation?

Excessive use of a code. Coding level 5 services and not preventive

medicine codes for annual physicals. Use of symbols or shorthand Lack of specificity about what you are

reviewing. (Review of systems as unremarkable is insufficient)

Frequent coding based on “time”

9921

199

212

9921

399

214

9921

50.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%CPT codes national average

CPT codes na-tional average

Procedural Coding There is a code for

every procedure that physicians perform

Each code dictates the price for that service that will be charged by the physician

Procedural Coding Each code is a five-digit number, which

identifies the procedure or service Health care entities (hospitals, clinics,

individual providers) attach a price to each code

Actual reimbursement will vary depending on what insurance companies or government payers will allow

Procedural CodingOrganization of codes

Anesthesia 00100-01999; 99100-99140 Surgery 10021-

69990 Radiology 70010-79999 Pathology & Lab 80048-89356 Medicine 90281-99199; 99500-

99602

Procedural CodingAdd-on codes Additional procedures that are

commonly done in addition to the primary procedure

Identified by terms like “each additional” Performed by same physician Cannot be reported separately

Procedural CodingModifiers Additional two-digit code that is added

to the primary CPT code Format: 11300-59 Some modifiers are attached to E & M

codes; others to procedural codes

Procedural CodingModifiers Both a professional and technical

component More than one physician and/or location Only part of a service was performed An adjunctive service was performed A bilateral procedure was performed Service or procedure performed more

than once

Procedural CodingGlobal Procedure Codes Most procedure codes are “global”, i.e.

they include ALL care related to that particular procedure

May or may not include initial encounter For example, fracture care includes

initial evaluation, treatment (splint or cast), follow up, and treatment of complications, if done by same provider

E & M Coding Evaluation and Management Billing for an E/M service requires the

selection of a Current Procedural Terminology (CPT) code that best represents: ❖ Patient type; ❖ Setting of service; and ❖ Level of E/M service performed.

E & M Coding The “level” of the code is then determined

by three components: Patient History Physical Exam Medical Decision Making

For a new patient, all 3 components are used. The lowest “level” determines the code.

For established patients, only 2 out of 3 are needed.

E & M CodingPatient Type For purposes of billing for E/M services,

patients are identified as either new or established: New patient -- has not received any

professional services from the physician/non-physician practitioner (NPP) or another physician (of the same specialty) who belongs to the same group practice in the past three years.

Established patient -- has received professional services as noted above in the past three years.

E & M CodingPatient Type “Any professional services” includes:

Emergency department visit Treatment as an inpatient (including

newborns) Nursing home visit Outpatient visit at any location

E & M CodingPatient Type Example #1

Joe comes in c/o cough. He has never been seen at FPC.

When reviewing his chart, you see that he had a knee replacement in 2012 at Allen.

Dr. Johnston was the attending physician. Family Practice was consulted for medical

management of his hypertension. Is Joe a new or established patient for

E & M Coding purposes?

E & M CodingPatient Type Example #2

Holly comes to the clinic for follow up of hypertension, diabetes and CHF.

She moved away in July 2011, but just moved back to Waterloo.

Her FPC chart contains a complete history, and her last office visit was 12/01/10.

You note that her medications were refilled by phone on 7/01/11.

Is Holly a new or established patient for E & M coding purposes?

E & M CodingPatient Type Example #3

While you are on team, you admit Alfred for CHF. Dr. Kettman is his PCP.

The following year, Alfred changes insurance carriers, and can no longer see Dr. Kettman.

He remembers the excellent care you gave him in the hospital, and comes to FPC to see you for his CHF.

Is Alfred a new or established patient for E & M coding purposes?

E & M CodingSetting of Service E/M services are categorized into different

settings depending on where the service is furnished. Examples of settings include: ❖ Office or other outpatient setting❖ Hospital inpatient❖ Emergency department❖ Nursing facility❖ Home

E & M CodingSetting of Service In each setting, there different types of

services which may be billed. OFFICE

Office visit Office consultation (new or est.) Preventive medicine services

Nursing Facility Initial nursing facility care (new or est.) Subsequent nursing facility care Nursing facility discharge

E & M CodingSetting of Service Hospital

Initial hospital care (new or est.) Subsequent hospital care Observation (admit/discharge same day) Hospital discharge Inpatient consultation

Emergency Department Emergency department visit (new or est.) Physician direction of EMS care

E & M CodingSetting of Service Critical Care

May be billed in hospital or ED setting Critical care E/M (first 30-74 minutes) Critical care (each additional 30 minutes)

Domiciliary or Rest Home Services Home Services

E & M CodingSetting of Service Prolonged Services

With direct patient contact Without direct patient contact

Anticoagulant Management Medical Team Conferences Care Plan Oversight Serices

Home health agency Hospice Nursing facility

E & M CodingLevel of Service Provided In general, the more complex the visit, the

higher the level of code the physician or NPP may bill within the appropriate category.

In order to bill any code, the services furnished must meet the definition of the code.

It is the provider’s responsibility to ensure that the codes selected reflect the services furnished.

E & M CodingLevel of Service Provided There are three key components when

selecting the appropriate level of E/M service provided: Patient History Physical Examination Medical Decision Making

The criteria for each component varies depending on the setting and type of service.

E & M CodingLevel of Service Provided Visits that consist predominately of

counseling and/or coordination of care are an exception to this rule.

For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.

E & M CodingLevel of Service Provided

E & M CODE

HISTORY EXAM MDM

99201 Problem Focused

Problem Focused

Straightforward

99202 Expanded PF Expanded PF Straightforward

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

E & M CodingLevel of Service Provided

E & M CODE

HISTORY EXAM MDM

99211 Nurse Visit ---- ----

99202 Problem Focused

Problem Focused

Straightforward

99203 Expanded PF Expanded PF Low Complexity

99204 Detailed Detailed Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

E & M CodingLevel of Service ProvidedPatient History Definitions

Problem Focused: CC, brief HPI Expanded PF: CC, brief HPI, pertinent ROS Detailed: CC, extended HPI, extended ROS,

pertinent PMH, FH and/or SH Comprehensive: CC, extended HPI,

complete ROS, complete PMH, FH and SH

E & M CodingLevel of Service ProvidedPatient History Definitions HPI Elements: (Brief 1-3; Extended 4+)

Location Duration Severity Modifying factors Context Timing Quality Associated symptoms

E & M CodingLevel of Service Provided

Patient History Definitions ROS Definitions

Pertinent=1 Extended 2-9 Comprehensive 10+

E & M CodingLevel of Service ProvidedOrgan Systems:

Constitutional Eyes ENT Cardiovascular Respiratory GI GU

Musculoskeletal Hematologic/

Lymphatic Neurologic Endocrine Psychiatric Skin Allergic

E & M CodingLevel of Service ProvidedPhysical Exam Definitions

Problem focused: limited exam of affected area

Expanded PF: limited exam of affected area and related systems

Detailed: extended exam of affected area and related systems

Comprehensive: general multisystem OR complete exam of affected system

E & M CodingLevel of Service ProvidedPhysical Exam Definitions Problem-focused: 1-5 elements in 1 or more

organ systems/body areas  Expanded problem-focused: 6 or more

elements in 1 or more organ systems  Detailed: at least 2 elements in at least 6

organ systems or body areas OR at least 12 elements in a single organ system 

Comprehensive: All elements of at least 9 organ systems or body areas OR all elements of one single organ system

E & M CodingLevel of Service ProvidedMedical Decision Making

Number of possible diagnoses and/or management options

Amount or complexity of information Risk of complications, morbidity, and/or

mortality

E & M CodingLevel of Service Provided

Medical Decision MakingNumber of possible diagnoses and/or management options STRAIGHTFORWARD:One self-limited or minor problem LOW COMPLEXITY:

* One or two self-limited problem(s) or symptom(s) * One stable chronic illness * Acute self-limited uncomplicated illness or injury * Risk of complications, morbidity or mortality is low

E & M CodingLevel of Service Provided

Medical Decision Making MODERATE COMPLEXITY:

* Three or more or self-limited problems * One or more chronic problems with mild to moderate exacerbation, progression or side effects * 2 OR 3 stable chronic illnesses * Undiagnosed new illness, injury or problem with uncertain prognosis * Acute illness with systemic symptoms * Risk of complications, morbidity or mortality is moderate.

E & M CodingLevel of Service ProvidedMedical Decision Making HIGH COMPLEXITY:

* One or more chronic illnesses with severe exacerbation, progression, side effects * Four or more stable chronic illnesses * Acute complicated injury with significant risk of morbidity or mortality * Acute or chronic illnesses that pose a threat to life or bodily function * Abrupt change in bodily function (e.g., seizure, CVA, acute mental status change) * Risk of complications, morbidity/mortality is high.