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©2013 MFMER | slide-1

Coding for Billing

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Copyright © The REACH Institute. All rights reserved.

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The presenter gratefully acknowledges theThe presenter gratefully acknowledges theutility of the utility of the AAP Coding for Pediatrics 2013AAP Coding for Pediatrics 2013

in the preparation of this presentationin the preparation of this presentation! !


Learning ObjectivesLearning Objectives

To increase understanding of adapting E/M & procedure codes to primary care-based child mental services

To describe basic applications of essential FTF procedure codes and strategies: 96110, Billing based on “Time spent counseling”, & Prolonged Service Codes

To review the key non-FTF codes relevant to PC-based child mental services


Why Should I Worry?Why Should I Worry?

Proper coding enables higher quality, evidence-based care and practices

Proper coding -> over time, results in increased coverage & reimbursement of widely used codes

Codes change regularly– Coders, practice managers often out-of-date!

Experience of past PPP participants– $10-$15K of practice income recouped


96127

(for rating scales)

96127

(for rating scales)


Rating ScalesRating Scales

Must be standardized Informal checklists don’t qualify Ex: ASQ-SE, PEDS, M-CHAT, Vanderbilt

ADHD, SCARED, PSC, PHQ-9, Connor’s ADHD, CBCL, BASC-2, BRIEF, CDS

May assign one unit of 96110 for each form completed, scored, interpreted and noted in the medical record


96127 Facts96127 Facts

No physician work included: premise is the scales are given to respondent, explained and scored by nonphysician

The physician work of interpreting the results and recording the results is included in the accompanying E/M work


Using 96127 w/ E/MUsing 96127 w/ E/M

Most insurer’s computer software requires a modifier to get the procedure through their system

Modifier may be appended to the E/M code or to the procedure code, but modifiers are E/M and procedure specific

If at first you don’t succeed, try another tactic!


Modifiers: An OverviewModifiers: An Overview

-25: Significant, separately identifiable E/M service by the same physician on the same date of the procedure or other service

- 59: “modifier of last resort”, & indicates distinct service from others on same day

- 76: also indicates distinct service from others on same day. Not used by Medicaid

(This is the modifier you use when you find an acute problem during a well check-up!)


Coding 96127Coding 96127

ExamplesExamples


Sue’s Visit: Option 1Sue’s Visit: Option 1

99383 (well-child, ages 7-11) 99214-25 (99214 – Elements, MDM) (2) 96127 (PSC, SCARED)

This is for insurers who allow -25 and multiple units of a procedure



99383 99214-25 96127 96127-76

This is for insurers who permit -25, but want each procedure on a separate line AND who do not adhere to CMS guidelines



99383 99214 96127-59 96127-59

This could be used for payers who do not permit -25 use and who also follow CMS guidelines regarding -76.


Sue: Next StepsSue: Next Steps

Behavioral rating scales sent to Sue’s teacher and request for interim grades

Possible telephone call from family before next visit

Is this all post-service work? Can this work be captured for payment?


Good News!: Non Face-to-Face Codes

Good News!: Non Face-to-Face Codes

• 99339-99340: Home Care Plan Oversight

• 99441-99449: Telephone Care

• 0074T: Online E/M Services

• 99080: Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting forms


Home Care Plan Oversight: IHome Care Plan Oversight: I

99339-99340 Individual physician supervision of a patient (patient not present) in home (or group home) requiring complex and multi-disciplinary care modalities

These 2 codes are for children w/ complex and chronic special healthcare needs living at home

Describes the work a physician provides on a monthly basis while performing complex supervision services to a patient in a home – (not skilled nursing facility)


Recurrent physician supervision of a complex patient or pt. who requires multidisciplinary care and ongoing physician involvement

Non-face-to-face Reflect the complexity and time required to supervise the

care of the pt. Reported separately from E/M services Reported by the MD who has the supervisory role in the

pt’s. care or is the sole provider Reported based on the amount of time spent/calendar

month

Home Care Plan Oversight: IIHome Care Plan Oversight: II


Services less than 15 minutes reported for the month should not be billed

99339: 15-29 minutes/month

99340: greater than 30 minutes/month

Home Care Plan Oversight: IIIHome Care Plan Oversight: III


Services might include:– Regular physician development and/or revision of

care plans

– Review of subsequent reports of patient status

– Review of related laboratory and other studies

– Communication (including telephone care) for purposes of assessment or care decisions w/ healthcare professionals, family members, legal guardians or caregivers involved in patient care

– Integration of new information into the medical tx. plan and/or adjustment of medical tx.

– Attendance at team conferences/meetings

– Development of extensive reports

Home Care Plan Oversight: IVHome Care Plan Oversight: IV


Services NOT included in care plan oversight:– Travel time to and from the facility or place of

domicile

– Services furnished by ancillary or incident-to staff

– Very low-intensity or infrequent supervision services included in the pre- and post-encounter work for an E/M service

– Interpretation of lab or other dx. studies associated w/ a face-to-face E/M service

– Informal consultations w/ health professionals not involved in the pt’s. care

– Routine post-operative care

Home Care Plan Oversight: VHome Care Plan Oversight: V


This code should not be used for intermittent telephone care to discuss a single topic, such as one lab result or care change.. That would not be “complex and multidisciplinary care modalities.”

Home Care Plan Oversight: VIHome Care Plan Oversight: VI


Home Care Plan Oversight: LogHome Care Plan Oversight: Log

Date Last Appt.

Date of Service

Service Action After

Service

Time Total Time/

month

2/8/10 2/20/11 TC: Talked w/mother re: severity of sxs

Offered to see Nora

12 min. --

2/8/10 2/21/10 TC: Explained need for scale to teacher

Waiting for scales

13 min.

2/8/10 2/24/10 Reviewed Teacher scale

Moved up Nora’s appt.

4 min. 29 min.


Non-Face-To-Face Service Coding: Telephone Care

Non-Face-To-Face Service Coding: Telephone Care

• 9944x: Telephone E/M service provided by a physician to an established patient, parent or guardian NOT originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appt.

• 99441: 5-10 min. medical discussion

• 99442:11-20 min. medical discussion

• 99443:21-30 min. medical discussion

• 99449: CAP-PCP medical consultation (Minnesota)


Telephone CareTelephone Care

Telephone care levels may represent three levels of complexity –need to document this to support charge

Documentation should:– Be thorough

– Fulfill the need for continuity of care

– Describe the complexity of the call

– Meet the requirements of the typical E/M visit

– A general note including the key elements of hx. and medical decision-making

– Time spent on call


Telephone CareTelephone Care

The call from the physician must be in response to a request from the patient or the family for this code to be used– (This rule does NOT apply to MN 99449

CAP-PC medical consultation codes)


School-Based MeetingsSchool-Based Meetings

Code w/ 99211-15 (est. Patient E/M codes) –On the basis of time; add prolonged services face-to-face if patient is present –and non-FTF if patient is not present if needed: payers may not pay for this, however

If teachers are the principal attendees, these should not be coded with the Medical Team Conference codes (99366-99368) as these descriptors specify interdisciplinary team of health care providers


Time Reporting: CPT Counseling Rule

Time Reporting: CPT Counseling Rule

• As of 2010, time must be used for code selection when the time spent in ‘counseling and coordination of care’ > 50% of the E&M visit

• The 3 key components of history, PE, MDM may be ignored– Only time is used to select the level of care

• A summary of the ‘counseling’ discussion should be included with the note

• Does not include screening time– Reported separately, with modifier (-25) appended to E/M


PearlPearl

Time is your friend in reportingmental health/ behavioral health/ developmental-focused services.

ALWAYS think of time first as the appropriate basis for valuing the visit.


Time: Basis forParent-Only Meetings

Time: Basis forParent-Only Meetings

• How to code for counseling and care coordination:– May be used when the patient is present or when

counseling a parent when the patient is not physically present

– Document the discussion’s topic

– When time spent in counseling and/or care coordination is over 50% of face-to-face time, CPT now says you must use this as the critical factor to qualify for a particular E/M service level

– Pediatricians spends the majority of parent-only conference on counseling→code based on time!


Documentation Requirements toBill Based on Time

Documentation Requirements toBill Based on Time

• The total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care

• The medical record must reflect the extend of counseling and/or coordination of care

• Resident/NP/PA face to face time can not be included (except under specialty specific Medicaid contracts)

• It is a good idea to document in a separate paragraph what documentation is supporting the counseling/coordination of care. This will make it easy to justify the time spent.


Time ExamplesTime Examples

• Good

– “I spent 40 minutes total time and 25 minutes was spent in counseling and coordination of care with the patient.”

– “I spent 40 minutes total time and more than 50% of the visit was spent in counseling and coordination of care with the patient.”

Assume elaboration in documentation of what was discussed with the patient.

• Bad

– “I spent 10 minutes talking with the patient about her diagnosis”

Why? Fails to show whether more than half the time of the visit was dedicated to counseling


Prolonged Services(99354-99359)

Prolonged Services(99354-99359)

• No longer add-on codes-put on separate line

• Reported in addition to other physician services, including E/M services at any level

• Code series defining prolonged services by:– Site of service– Direct or without direct patient contact– Time

• Total time for a given date, even if the time is not continuous

• Time must be of 30 minutes or more


Prolonged ServicesProlonged Services

Direct Patient Care Outpatient

Face-to-Face 99354: first 30-74 min

Face-to-Face 99355: each add 30 min >75

Before or after Face-to-Face99358: first 30-74 min of non face-to-face

Before or after Face-to-Face99359: each add 30 min >75 min


Prolonged Visit Coded on Complexity

Prolonged Visit Coded on Complexity

• If your E/M level was made based on complexity, AND• visit runs more than 30 minutes over the

code time description, AND• total counseling/care coordination time is

not > 50% • THEN you may add the prolonged service

code to account & describe the extra time.


Panel & Discussion

Q & A

Panel & Discussion

Q & A


SummarySummary Understanding Coding & Billing is essential to enable

doing quality PC mental healthcare services – someone has to “mind the store”!

Business managers, coders, etc., often out-of-date. How will I ensure continued updating in my practice setting? – Codes vary setting to setting, company by company, state-

by-state, and year-to-year Which of these 4 key coding opportunities need to be

further investigated, and possibly put into my practice?


ResourcesResources

www.aap.org/sections/schoolhealth www.aap.org/mentalhealth www.aacap.org www.schoolpsychiatry.org http://www.mnpsychconsult.com

(for Minnesota PCPs and CAPs!!)

[email protected]


Appendix of Basic Coding Information

Appendix of Basic Coding Information


CPT and ICD-9-CMCPT and ICD-9-CM

• ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification– Why the service was done

– Information collected by payers to manage risk (preexisting conditions; refused diagnoses)

• CPT: Current Procedural Terminology– What was done

– Provides the basis for payment


ICD-9-CMICD-9-CM

• ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification

– Why the service was done

– Information collected by payers to manage risk (preexisting conditions; refused diagnoses)

• Important point: The Health Insurance Portability and Accountability (HIPAA) Act of 1996 requires payers and physicians to use ICD-9-CM. As revised ICD-9-CM codes are activated, you must use these updated codes. Obviously, these codes explain to payers the specific reason a patient was seen.


ICD-9-CMICD-9-CM

• The reason for the service (visit)

• The first diagnostic code reflects the condition the professional is actively managing: – “the reason for the visit”

• Subsequently listed codes– Factors important to condition #1 – Coexisting conditions tx. and mgment of #1

• If a child is seen for a residual condition (e.g. hearing deficit), code this first with the cause of the condition as a secondary ICD-9-CM code (e.g. meningitis)


ICD-9-CM “The Top→Down View”

ICD-9-CM “The Top→Down View”

• Code to the highest degree of specificity

• Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results

• Probable, suspected, questionable, or rule out should not be coded

• List the ICD-9-CM code that is identified as the main reason for the service first, then list co-existing conditions

• Chronic disease treated on an ongoing basis may be coded

• Do not code for conditions previously tx that no longer exist


ICD-9-CMICD-9-CM

• Do code only the conditions/problems you are actively managing at the time of the visit and diagnoses affecting the current status of the child

• Do not code for previously treated conditions

• May include conditions existing at the time of the patient’s initial contact as well as conditions developing subsequently affecting treatment

• Dx. relating to a pt.’s previous medical problems w/ no bearing on the present condition are not coded.


ICD-9-CMICD-9-CM

• Do not code dx. listed as “rule out,” “probable” or “suspected” –they are not established in out-patient practice

• Do code to the highest degree of certainty

• Do not code symptoms if a dx. has been made: Ex.: If a child w/ dx’d ADHD is seen for routine med. monitoring and headaches are reported w/ meds.: code 314.01 first, then headache as #2.


NEC and NOSNEC and NOS

• Residual Categories

– NEC: Not elsewhere classifiable: conditions specifically named in the medical record but not specifically listed under a code description

– NOS: Not otherwise specified: a diagnostic statement lacking detail in describing a specific condition (e.g. 314.9 unspecified hyperkinetic syndrome)


PearlsPearls

• Code the diagnosis to the highest level of certainty (the words in the descriptor)

• Code the diagnosis to the highest level of specificity (the numbers in the descriptor)


PearlsPearls

• Remember, a chronic condition, such as ADHD or depression, managed on an ongoing basis may be coded and reported as many times as applicable to the patient’s treatment.

• The level of the E/M visit may change as the complexity of the child’s needs change.


CPT and MH CodingCPT and MH Coding

• Current Procedure Terminology = CPT

– A tabular listing of almost all known encounters w/patients

– Published annually (Oct. 1) by the AMA

– Includes codes for cognitive, procedural and supplies

– Services may be provided in any location

– Codes not limited to specialty: ANY physician may use any code

– Codes should be chosen most accurately describing the service provided


RVU Components ofMedical Provider WorkRVU Components of

Medical Provider Work

• Pre-, intra-, post- service work

– Time to perform the service

– Technical skill and physical effort

– Mental skill and judgment

– Psychological stress associated with iatrogenic risk


CPT UpdatesCPT Updates

• Documentation guideline revisions by CMS and AMA: www.cms.hhs.gov/MLNProducts

• AAP updates on these: www.aap.org; AAP News; AAP Pediatric Coding Companion newsletter

• AACAP updates published in their newsletter


Selecting a Procedure CodeSelecting a Procedure Code

• First, you must select a procedural code appropriately reflecting the service provided based on:

• Your knowledge of the patient (new vs established)

• The complexity of your encounter

• Face-to-face time spent on your encounter

• The ‘nature’ of the encounter


Coding the VisitCoding the Visit

• When selecting a procedure code, the ideal goal is to completely describe all the services provided to the patient at that visit. Evaluation and Management (“E&M”) procedure codes are the basic physician visit codes. E&M codes include:

– Consultation codes: 99241-99245

– New patient visits: 99201-99205

– Established patient visits: 99211-99215

– Preventive care visit (primary care, not specialty service)


HistoryHistory

Type of Visit

HPI ROS PFSH

Problem focused

Brief 1-3 N/A N/A

Expanded problem focused

Brief 1-3 Brief (1) N/A

Detailed Extended 4+ Extended (2-9) Pertinent (1)

Compre-hensive

Extended 4+ Complete (10+) Complete(2/3 or 3/3)


Physical ExamPhysical Exam• Problem Focused

– Limited to affected body area or organ system– 1 body area/organ system

• Expanded Problem Focused– Affected body or organ system and other symptomatic or related

organ system– 2-4 body areas/organ systems

• Detailed – Extended exam of affected body area(s) and other symptomatic or

related organ systems– 5-7 body areas /organ systems

• Comprehensive– Complete single system specialty exam or– Complete multi-system exam– 8 or more body areas/organ systems


Medical Decision MakingMedical Decision Making

• Number of possible diagnoses and/or management options

• Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed

• Risk of complications, morbidity and/or mortality, associated with the patient’s presenting problem. Includes need for diagnostic procedures and management options


Medical Decision MakingMedical Decision Making

Decision MakingNumber of Diagnoses

Amount of Data

Risk of Complication

Straight forward Minimal Min. or None Minimal

Low Complexity Limited Limited Low

Moderate Complexity

Multiple Moderate Moderate

High Complexity Extensive Extensive High


E/M DocumentationE/M Documentation• Read the CPT descriptor to identify the

documentation needs of your code– E.g. E/M codes: “Key elements:”

– Date of service

– Name of referring professional (if consultation)

– Time spent in encounter (if counseling and care coordination is > 50% of total face-to-face time)

– Chief complaint

– Pertinent history

– Physical exam

– Laboratory or developmental testing results (if done)

– Impression w/ differential diagnosis

– Treatment recommendations, including medications

– Follow-up plans


Office Visit: New PatientOffice Visit: New Patient

Codes 99201 99202 99203 99204 99205

HistoryProblem Focused

Expanded Problem Focused

Detailed Comprehensive Comprehensive

ExamProblem Focused



Decision Making

Straight Forward

Straight Forward

Low Complex

Moderate Complex

High Complex

Time FF 10 20 30 45 60

Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3


Office Consultation: NewOffice Consultation: New

Code 99241 99242 99243 99244 99245

HistoryProblem Focused



ExamProblem Focused



Decision Making

Straight Forward

StraightForward

Low Complex

Mod Complex High Complex

Time FF 15 30 40 60 80

Key # 3/3 3/3 3/3 3/3 3/3 3/3


Consultation/New Pt. Requirements: Complexity

Consultation/New Pt. Requirements: Complexity

• 99244

• HPI-4 elements, ROS-10+, PFSH-3

• PE-8 elements, must be organ systems: Const, Eyes, ENT, Resp, CV, GI, GU, MS, Skin, Neuro, Psych, Heme/Lymph

• Medical Decision Making-MODERATE

• 99245

• HPI-4 elements, ROS-10+, PFSH-3

• PE-8 elements, must be organ systems: Const, Eyes, ENT, Resp, CV, GI, GU, MS, Skin, Neuro, Psych, Heme/Lymph

• Medical Decision Making-HIGH

The difference between a level 4 and a level 5 isonly the Medical Decision Making


Office Visit: ConsultationsOffice Visit: Consultations

• Consultation is a service provided by a physician whose opinion or advice is requested by another physician or other appropriate source**

• Consultant may initiate diagnostic and/or therapeutic services

• Consultant must document:– Request for consultation (written or verbal)– Need for consultation– Opinion and services ordered and performed– Communication by written report back to the referring

source– The patient was returned to the requesting physician’s

care


“In House” Consultations“In House” Consultations

• If you accept an ‘in house’ consult, you still must adhere to the “3 R’s”!

– You and the requesting physician must document the medical necessity and reason for the consult.

– You must render an opinion.

– After you see and evaluate the patient, you must give the requesting physician a report – but this ‘report’ may be your summary in the group chart if you’re sharing a group chart.


Medical Services to Remember!Medical Services to Remember!

69210 Removal impacted cerumen, one or both ears– e.g. Child w/ ADD eval and questionable hearing: can’t get reliable

OAE due to impaction in one ear

• Must report different dx. for the removal and the E/M service and should have two separate notes for the two procedure codes, both notes should clearly describe the separate nature of the services

– 99244-25 New pt. consultation w/ separate procedure

– 314.01 Attention Deficit Disorder-Combined Type

– 69210 Removal impacted cerumen, one or both ears

– 380.4 Impacted cerumen


ReferencesReferences

Lear, JG, Isaacs, Stephen L, Knickman, JR. School Health Services and Programs. Princeton,NJ: Robert Wood Johnson Foundation, 2006.

US Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999


ReferencesReferences

American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics, 2008.

AAP Committee on Coding and Nomenclature. Coding for Pediatrics: A Manual for Pediatric Documentation and Payment, Fifteenth Edition. Elk Grove Village, IL: Academy of Pediatrics, 2010.

AAP Committee on Coding and Nomenclature. aappediatric coding newsletter .Elk Grove Village, IL: Academy of Pediatrics, 2010.


ResourcesResources

Committee on Children with Disabilities et al. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 116 (1), July 2006; 405-420.

Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children’s Health. Data Resource Center for Child and Adolescent website: www.nschdata.org

RUC Database: www.catalogue.ama-assn.org or call 800/621-8335

©2013 mfmer | slide-1 coding for billing. copyright © the reach institute. all rights reserved....

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