cpt coding: beyond the basics

CPT Coding: Beyond the Basics

AANP NATIONAL CONFERENCE 2010Barb Pierce, CCS-P, ACS-EM

Barb Pierce Coding and Consulting, [email protected]

Barb Pierce, CCS-P, ACS-EM 2

Objectives Review the overall billing process,

including CPT, HCPCS, and ICD-9 coding systems 30 minutes

Review the codes used on a daily basis 90 minutes

Review surgical coding, proper use of modifiers and other coding concepts 60 minutes


Outline E/M codes

Office, hospital, consultations, preventive medicine

Injections and immunizations Lacerations, lesions and other minor

surgical procedures Modifiers ICD-9 coding and linking Coding for compliance


The codes CPT

Main coding system that describes what was done

HCPCS Further specification of some CPT codes,

including supplies ICD-9

Describe why the service was performed, diagnostic statement


Billing the codes The “what” and the “why” need to

be linked and must meet medical necessity

The encounter form (superbill) needs match the information in the medical record


Billing for the Provider Billing rules for the Nurse

Practitioner Own number Incident to Medicare versus everybody else Split/shared visits Consultations


E/M Coding New vs. established and initial vs.

subsequent What is a new patient?

Determined by site of service Follow the HCFA/AMA

Documentation Guidelines to choose the level


New vs. Est Patients Per CPT: Solely for purposes of

distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). Cardiologist read an EKG on a patient a year

ago without a face-to-face visit. NP in same group sees the patient on 1/15/10.

New patient


New vs. Est Patient Per CPT: A new patient is one who has not received any

professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Dr. FP1 saw the patient for bronchitis six months ago. NP is now seeing the patient for abdominal pain.

Established patient to Dr. FP2 Dr. Heart (general cardiology) saw the patient for

HTN six months ago. Now the patient is seeing Dr. Vessel (interventional cardiology) for coronary artery blockage six months later.

Established patient to Dr. Vessel


New vs. Est Patient Watch for specialty designations, as

recognized by Medicare Example on previous slide, no different

specialty designation for Dr. Heart and Dr. Vessel

Dr. Podiatry and Dr. Back in the same Ortho group. These are recognized as different specialties according to Medicare. So, if Dr. Podiatry saw the patient within the past 3 years and now Dr. Back is seeing the patient, Dr. Back could bill a new patient visit.


E/M Section Key components

History Examination Medical Decision Making Some require 3/3 Some require 2/3 Coding by time instead


Office/Other outpatient services 99201-99215 Codes don’t crosswalk, i.e... 99213

compared to 99203 Office and where else? 99211 … be careful Hints for construction of encounter

form


Consultations 2010 … CPT A consultation is a type of evaluation and management

service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem

The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source. The consultant’s opinion and any services that were ordered or performed must be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source.

Still cautioned about transfer of care Billing for consultations based on new wording “on the

unit”

Barb Pierce Coding and Consulting, LLC 14

Consultations 2010 … Medicare Medicare has decided not to pay for consultations starting in

2010. Instead the RVU’s have been reallocated and increased for the other visit codes.

Office, use new or established patient visit codes (3 yr rule will apply)

Hospital and Nursing Facility, use admission codes Office: Codes formerly used for consultation services 99241 –

99245 crosswalk exactly with documentation requirements of 99201 – 99205. If patient seen in last 3 years by physician of same group of same specialty, then use 99212 – 99215.

Hospital and Nursing Facility: Codes formerly used for consultation services 99251 – 99255 do not crosswalk with admission codes (5 levels of consults versus 3 levels of admissions)


Observation codes Based on patient status Admit to OBS 99218-99220 Discharge from OBS 99217 What if patient is held in OBS for 3

calendar days? Admit and discharge from OBS

same date 99234-99236


Medicare Coding for OBS patients Consultations for patients in OBS

status The ordering physician for the OBS

status will use the OBS admission codes 99218 – 99220

The “specialist” will use the outpatient visit codes 99201 – 99215

Three year rule will apply


Inpatient Services Admission 99221 - 99223

H/E/MDM similar to 3,4,5 new patient/consult codes

admission from the office…bill the office visit or the initial hospital care?

daily visits without an initial hospital code first

Admit/discharge same date: 99234-99236


Inpatient Admissions 99221 requires

Detailed history and Detailed exam and Straightforward medical decision making

99222 requires Comprehensive history and Comprehensive exam and Moderate medical decision making

99223 requires Comprehensive history and Comprehensive exam and High medical decision making


Hospital Admissions No three-year rule For Medicare, the admission code will be billed

by the “physician-formerly-known-as-a-consultant” per hospital admission. Multiple physicians may be billing the 99221 – 99223 on the same patient. Admitting physician of record will use modifier -AI. Oncologist saw the Medicare patient during

an admission six weeks ago. The patient is admitted again, the oncologist is “consulted” again (for the same or a different problem). Oncologist bills 99221-99223.


Inpatient Admissions CPT’s intent of 99221 – 99223:

Report the first hospital inpatient encounter Not necessarily the date of admission Not used if patient seen subsequently that date and

discharged New for 2010, these are the codes recognized by

Medicare for all physicians seeing the patient for the first time during a hospital stay

Used in place of consultation codes If documentation is less than documentation

requirements for 99221, use the unlisted code 99499 or subsequent hospital visit code 99231 – 99233.

Admitting physician of record will use modifier -AI

Diagnosis coding issues … medical necessity will prevail


Modifier for Admitting Physician of Record What modifier should the admitting physician

of record use? AI is a new HCPCS modifier for “principal

physician of record” Informational modifier Specialist claims should not be held up if

admitting physician of record forgets to use the AI

If AI is used unnecessarily, claims should not deny … no edit in place currently


Inpatient Services Subsequent hospital care 99231 -

99233 Only need 2/3 key components Can’t bill for more than one/day Code by time when appropriate Discharge: 99238 or 99239 based

on time…and what is included in that time


Inpatient Discharge 99238

Discharge day management, 30 minutes or less 99239

Discharge day management, more than 30 minutes Documentation must indicate that >30 minutes

spent and why Includes:

Final evaluation of the patient Discussion of hospital stay Instructions (may include caregivers) Preparing discharge records, prescriptions and

referral forms


OBS or Inpatient Care - Admit and Discharge Same Date Same calendar date Can be used for OBS or inpatients Medicare guidelines require that the patient be there at

least 8 hours if using these codes and provider must document that fact

Patient could be inpatient status or OBS status … codes are the same, place of service would be different

99234, 99235, or 99236 (same criteria for history, examination, and MDM as other admission codes)

Require two face-to-face visits Why? The RVU for these codes = admit + discharge Face-to-face for one and phone call for other won’t

work If only seen once, then bill for the service rendered,

which might be the admit (inpatient or OBS) or it might be the discharge


Nursing Facility services Nursing Facility Codes Include SNF, even if bed located in hospital

setting Don’t forget the discharge codes 99315-99316

based on time Hospital discharge and nursing facility

admission on same date IF both services meet criteria

For Medicare, the service formerly reported as a consultation will now be reported as an admission to the facility.


Domiciliary Services Facilities without a medical

component Can be used for Assisted Living

facilities


Emergency Department codes “organized hospital-based facility”…

must be available 24 hours a day Five levels 99281 - 99285 with different

criteria than office visits Can’t code by time Specialists should used consultation

codes instead, if criteria met (except for Medicare)


ER Visits 99281 – 99285 Codes usually used by the provider

assigned to the ER Could be possible for more than one

provider to use this code on same patient But … probably a consultation or office/out-

patient service instead However, for Medicare, multiple physicians

are to use the ER codes (in place of consultation codes)


Medicare Resources Prolonged Services

MLN Matters MM5972 7/1/08 http://www.cms.hhs.gov/MLNMattersA

rticles/downloads/MM5972.pdf Critical Care

MLN Matters MM5993 7/7/08 http://www.cms.hhs.gov/

MLNMattersArticles/downloads/MM5993.pdf

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf


Preventive Medicine When considering the billing

options for preventive medicine, we must keep in mind: We intend to submit accurate

information to health insurers. We will not misrepresent the

nature or purpose of encounters in order to receive insurance reimbursement.


Preventive Medicine When an appointment is

scheduled, attempt to determine the nature of the visit so as to allow adequate time for the service. Patient education could occur at that time.

Are you going to take care of everything today and split bill?


PM with E/M Define “additional work” E/M codes require a chief

complaint and history of present illness

From an auditing standpoint, expect additional history and medical decision making


CPT Codes 99381-99397 are for preventive medicine

services are defined by the patient’s age in two categories: new or

established require comprehensive history and

comprehensive examination (but not same definition as comprehensive in E/M Documentation Guidelines)


MEDICARE P/P/B Medicare will pay every two years

for a screening pap, pelvic and breast exam for females at low risk G0101 is for the pelvic and breast

exam, requires 7/11 elements on exam

Q0091 is for collection of Pap smear Paid yearly for patients at high risk Can bill E/M-25, G and Q on same

date


G and Q Use ICD-9 codes V76.2, V76.47, or

V76.49 for patients at low risk Each ones pays $30.00 + Paid every two years for low risk If unsure when patient last had

these services, get an ABN signed and use -GA modifier


E/M, G, and Q Document and code the E/M

service at the appropriate level based on history, exam and decision making. Modifier -25 and diagnosis(es) for problems addressed

Bill the G0101 and Q0091 additionally with V code as diagnosis


Medicare Carve Out 99397 9921X-25 G0101 Q0091 (?) Any combination of above, based

on documentation Patient pays 99397 minus

Medicare allowed services


What about the guys?? Medicare digital rectal exam

G0102 Medicare PSA G0103 Here’s the good news: both are

paid yearly Here’s the bad news: both are

bundled with E/M code if done on same day


Other preventive medicine services Other than these E/M services,

Medicare also pays for other screening, preventive services.

Research your Medicare bulletins Welcome to Medicare Physical

Much better with 2009 changes Some screening labs for diabetes

and cardiovascular disease

Barb Pierce, CCS-P 40

E/M Documentation Guidelines E/M Documentation Guidelines:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html






E/M Coding and Auditing Documentation must support the

level of service billed Service performed vs. level billed

vs. level documented 95 vs. 97 Documentation

Guidelines


General Principles Record must be complete and

legible Even the signature or identification Record stands on its own…but can

incorporate by reference Signature log


3/3 or 2/3 ?? Key components = history,

examination, and medical decision making

New patient visits, consultations, hospital admits require 3/3

Established patient visits, daily hospital care require 2/3


History ROS and PFSH can be incorporated by

reference by reviewing and updating prior information, noting the date and location of earlier information…but not HPI

Can also incorporate by reference information recorded by ancillary staff or patient

If unable to get history, say why “all others negative” “noncontributory”


Examination 1995 guidelines are more generic by

body system How do you apply the ’95 exam criteria?

1997 guidelines are very specific..the “bullets” numeric requirements must be met parenthetical examples are for clarification

and guidance only “and” really means “or”


Medical Decision Making Based on the average of :

number of diagnoses/management options

data to be ordered/reviewed risk (nature of presenting problem,

diagnostic procedures, management options)


Medicine Section Immunizations and injections

require 2 codes: the administration and the supply 96372 with J code (watch for units) 90471 for one vaccine 90472 for each additional vaccine code the actual vaccine additionally


Surgery Section Global surgery package includes

pre-op day(s) and post-op days Medicare Fee Schedule is good

resource…some minor procedures have a post-op period


Surgery Section Separate procedure designation …

code only if it is the only procedure done. Example: exploratory laparotomy

Bundled with more extensive procedure

May be the approach Watch for CCI edits (Correct Coding

Initiative) which bundle certain services


CCI Edits Published by NTIS and updated quarterly Other resources may include other coding

standards Misuse of Column 2 with Column 1

20550 Injection tendon sheath is a therapeutic injection. If 20520 (removal of foreign body) is done, it would be a misuse if code 20550 is billed to represent injection of local anesthesia to do the 20520


Coding Edits Surgical package and separate

procedure concepts Designation of sex Family of codes Most extensive procedure:

simple/complex, superficial/deep, incomplete/complete

Sequential procedures With/without Mutually exclusive


Surgery Section Lacerations

Need location, size, type of repair (simple, intermediate, complex)

Add laceration lengths if same type of repair and same anatomical site

Have the provider be specific on the encounter form

Additional E/M only if significant, separately identifiable services done, then add -25


Surgery Section Lesions

Need location, size, type of removal or destruction

Lesion size vs. excised size Destruction codes changed for 2007 May need a special lesion removal charge

ticket For removals, hold for path report to

determine if benign or malignant Don’t rely on path report for size or number

of lesions


Surgery Section Fracture care codes

Global periods Bill casting materials additionally Re-casting can be billed additionally Casting or splinting can be billed if

done to stabilize Medicare has special Q codes

(HCPCS) for splint and cast supplies


OB Maternity care and delivery should be billed as

a global OB package unless you only did part of the OB care Antepartum care (code based on number of

visits) Delivery (different codes vaginal delivery vs.

cesarean delivery) Postpartum care No special codes for high risk. Bill

additional E/M codes separately “package” may vary by insurance company


Medicare Physician Fee Schedule Data Base - MPFSDB

Indicator list Gives information about specific

codes Updates quarterly by CMS


Modifier –24 Unrelated E&M service

E&M service by the same physician during a postoperative period for condition not related to surgery

Global periods of 0-10 and 90 days Individual payers define postoperative

period Diagnosis code identifies the reason for the

E&M as unrelated to the procedure Informational modifier - claim gets paid Examples


Modifier -25 Modifier -25

Indicates a significant, separately identifiable E/M service by the same physician on the same day as another procedure or service

Use on E/M code Examples


Modifier –26 Professional Component

Professional portion for procedures that are a combination of professional and technical components

Provider must prepare a written report Medicare fee schedule P/T column

Appropriate to use -26 modifier Global code - payment for both components -26 Payment for professional component -TC Payment for technical component Check indicator number for P/T


Modifier -50 50- Bilateral procedure

Indicates bilateral procedures performed during same operative session

Verify if code description states procedure is bilateral

Payment based on 150% of fee schedule

Use one line item with # of services “1”


Modifier -51 51- Multiple procedures

Indicator 0- does not apply- do not use 51

Indicator 2- does apply( 100%, 50%, 50% etc.)

Indicator 3- special endoscopy rules apply if billed with another endoscopy code.

Indicator 9- does not apply- do not use 51



Decision for surgery with supporting documentation

Use on E/M code to keep it out of the global package

Applies to major procedures for scopes and procedures with 10 day

global, use -25 modifier instead (especially Medicare)



Used to identify procedures or services that are normally reported together, but need to indicate a particular circumstance such as different encounter, different procedure, different site

Modifier of last resort Will bypass CCI edit…should not be

used routinely to bypass the edit


CCI cont. 59- Distinct procedural service

Separate encounter, different site/organ system, separate injury, procedures performed on same day by same physician

Appropriate under certain circumstances Example02/15/09 17000 destruction of

lesion hand02/15/09 11000-59 biopsy of arm


ICD-9 Coding ICD-9-CM codes describe “why”

the service was performed Be specific !!! Always confirm the

code Code what you know at the time

the service is performed…signs and symptoms are okay


ICD-9 Coding There are two volumes…use

both !! Note the main terms Use the alpha index to locate main

term Look for modifiers, subterms, notes

and cross-references Select a tentative code Confirm in the tabular Code to the highest level of specificity


ICD-9 Abbreviations NEC: Not elsewhere classifiable

means the coding system limits the code selection, such as “other”

NOS: Not otherwise specified means the documentation was unspecified Is there more specific information

available? Develop a “hit list” of unspecified

codes


ICD-9 Unspecified codes Diabetes Musculoskeletal diagnoses or

symptoms without a specific location

Hypertension Illnesses that are acute or chronic Others???


Coding Signs & Symptoms Definitive diagnosis not available Possible, probable, rule out Used widely in primary care Check out Chapter 16 which

includes many signs, symptoms, and ill-defined conditions. Also the location for abnormal test result codes


V Codes Describe a reason for the

encounter without active illness Personal history and family history

of malignant neoplasms V codes are our friends and can be

used as the primary code Codes for preventive medicine

services


V Codes Look for terms such as: admission,

examination, problem with, aftercare, history of, screening for, supervision of, attention to, observation for, status (or status post)

Pre-op evaluations: V72.8_ Personal and family history of

malignant neoplasms: V10 and V16 codes


Diagnosis Code Linking Helps identify medical necessity Helps justify the reason for the CPT

code Multiple codes present

challenges…who links? Does your encounter form allow for linking?

LCD’s, NCD’s, and ABN’s ICD-10


Waiver or not? Screening tests - no waiver if

due to statutory exclusion Screening tests - waiver if

sometimes payable (frequency)

Tests not meeting medical necessity criteria require the waiver


Modifiers for ABN situations GY: item or service statutorily

excluded or does not meet definition of any Medicare benefit (will result in denial)

GZ: item or service expected to be denied as not reasonable and necessary…without ABN signed

GA: ABN signed and on file


Compliance Work your compliance plan Education Monitoring Correction Internal reviews External reviews


Patient, Physician and Staff Education Patients need to understand the

rules Use information provided by the

carrier Make sure staff know the rules Let physicians know how they can

help Create policies and procedures Use carrier provided patient

education


Areas to Monitor/Look for Improvement Compare the medical record,

encounter form, and CMS-1500 (or computer entry)

Do all three tell the same story? Level of service for E/M Type of E/M service Provider of service Date and location of service


Templates and other tools History forms completed by patient or

staff with past history, family history, social history, and system review

Progress notes that prompt the provider of documentation requirements (and may reduce transcription costs)

Build a helpful encounter form Common procedures ICD-9 codes ?


Coding Compliance Medical necessity above all else,

regardless of documented history or examination

Follow incident-to rules Follow teaching rules


Incident to Services Office only Incident to provider on site Incident to provider’s already

established care plan, so no new patients or new problems

PA’s and NP’s can bill this way or under their own provider numbers


Teaching Rules Residents are individuals in an approved

GME (graduate medical education) program…includes interns and fellows

Carriers Manual Section 15016 … revisions

Teaching physician has to document presence and participation in service

Clarifications of what medical students can and cannot document


Teaching Rules Can’t code by time Special rules for procedures…key

portions Medical Students are not residents For tying into resident note, the

following are NOT adequate: signature only seen and agree with signature reviewed resident’s note and agree


Policies and Procedures/Education 99211 Procedures with E/M Use of modifiers New vs. established patients Incident-to rules Teaching rules Importance of ICD-9 coding and linking NCDs and LCDs … need for ABNs


Keep going …. Preventive medicine and split

billing Consultation codes Proper documentation of time Look at some EOB’s


Post-test Questions PreviewTo receive CE credit, the post-test and evaluation must be completed online at www.aanp.org/ce. If you successfully answer at least 70% of the test items, you will be able to print a certificate. For questions or more information concerning this online CE opportunity, please contact Stormy Causey, CE Coordinator at [email protected]. This program provides the following Post-Test Preview as a convenience, ONLY to help in preparation for the online Post-Test. Credit is awarded for tests completed online.

1. CPT codes represent:a. Diagnosisb. Proceduresc. Patient demographicsd. Fees

2. CPT classifies a new patient as one who:e. Has never been seen by the providerf. Has not been seen by a member of the same group of the same specialty in three yearsg. Needs a new medical record and account establishedh. Is referred by another provider

3. The global surgery package:i. Applies to all CPT codesj. Allows you to bill for post-op office visitsk. Includes some pre-op and post-op servicesl. Does not apply to procedures performed in the office


Post-test Questions Preview (cont.)

4. An Advanced Beneficiary Notice (ABN) is required:a. In situations where you believe Medicare may deny the service based on the limitations of a

local or national policyb. On every service provided to a Medicare patientc. So that Medicare can bypass their edits and pay you for everythingd. On all screening tests

5. The difference between 99212 and 99215 is:e. The amount of time spent taking the historyf. Whether a PCP or specialist provided the serviceg. The fact that 99215 is reserved for new patientsh. The amount of history, examination, and medical decision making that must be performed and

documented6. An office visit and minor procedure on the same day:

i. Will always be paid and you won’t need a modifierj. Require documentation of significant and separately identifiable history, exam and/or medical

decision making over and above the procedurek. Must be performed at two visits at separate times l. Cannot both be billed


Post-test Questions Preview (cont.)

7. Time overrides history, examination, and medical decision making for those patient encounters where the majority of the visit is spent counseling the patient.a. Trueb. False

8. Since Medicare no longer pays for consultations, patients who present to the office for a pre-operative clearance would always be coded as new patients.c. Trued. False

9. Code G0101 is:e. Paid by Medicare every yearf. The code accepted by Medicare for a screening breast exam, pelvic exam and collection of a

Pap smearg. Never to be billed in addition to 99213h. The code used to describe a digital rectal exam for males

10. If the patient presents with abdominal pain and is sent to the hospital for further testing to rule out appendicitis, the diagnosis for the office visit would be :i. Abdominal painj. Appendicitis

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