coding compliance for the chiropractic practice 2015 anthony w. hamm, dc, faco

Coding Compliance for the Chiropractic Practice 2015

Anthony W. Hamm, DC, FACO

Coding Resources

• AMA CPT primary source reference

• ICD-9-CM (10)

• RBRVS CPT code values (CMS driven)

• HCPCS codes

• ChiroCode Deskbook, 2015

CPT Coding

• Choose the code that best describes the service provided

• Codes reported should be within the scope of practice of the provider and be clinically indicated

Telling the Story

• Both documentation AND code reporting tell the story of the patient encounters

• Diagnoses tell why we did something

• Level of exam indicates the complexity of patient condition

Evaluation & Management

• Office/Outpatient services 99201-99215

• Most scrutinized codes by carriers

• Most common mistakes are due to misinterpretation of descriptions and definitions

• Must understand concept of key components

Terminology

• New Patient-A new patient is one who has not received professional services from a provider or another provider of the same specialty who belongs to the same group practice within the past 3 years

• Established Patient-A patient who has received professional services within the past 3 years from the provider or another provider of the same specialty who belongs to the same group practice

• Chief Complaint-A concise statement from the patient describing the symptom, problem, condition, diagnosis, or other factor that identifies the reason for the visit

Terminology (cont)

• Concurrent Care-When more than one provider provides services to a patient on the same day. Payment for concurrent care is determined by establishing medical necessity for services performed by more than one provider

• Counseling-A discussion with the patient and/or family regarding diagnoses, test results, medication management, care instructions, prognosis, or other factors related to the patient’s condition

• History of Present Illness-A chronological description of the development of the patient’s present illness, or problem from onset to present. This must be documented by the provider and not ancillary staff

Terminology (cont)

• Medical Decision Making-The process for describing the outcome of the visit, through consideration of the nature of the presenting problem, diagnoses, treatment and/or management options, diagnostic tests and procedures ordered, complexity of the condition and risk for complications

• Morbidity -The quality or state relative to a disease process

• Mortality -The number of deaths in a given time or place

Terminology (cont)• Nature of Presenting Problem -A disease, condition, illness, injury, sign, finding or

complaint for which the patient is being seen. The five types are:

• Minimal–Services may not require the presence of a provider, however, services are rendered under a provider’s supervision

• Self-Limited or Minor–A problem that typically runs a definite course, is transient in nature, and not likely to permanently alter health status

• Low Severity–A problem in which the risk of morbidity without treatment is considered to be low; there is minimal risk of mortality without treatment; and full recovery is expected

• Moderate Severity–A problem for which the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment or there is some uncertainty of the prognosis or potential for functional impairment

• High Severity–A type of problem in which the risk of morbidity and/or mortality without treatment is high to extreme. There exists a high probability of severe or prolonged functional impairment

Terminology (cont)

• Past History -A review of the patient’s own medical history related to trauma, illness, previous surgeries and hospitalizations, including medications, allergies and other pertinent information

• Social History -A review of events and activities describing the patient’s lifestyle, e.g.. marital status, education, employment, sexual history, substance use or other relevant social factors

• Review of Systems-An inventory of the body systems acquired through a series of questions asked to the patient. The review of systems helps define possible management options

Terminology (cont)

• Face to Face Time -This includes only the time the provider spends face to face with the patient obtaining the history, performing the examination and counseling the patient and/or family

• Consultations –Services provided by a provider whose opinion or advice is requested for a specific condition or problem by another provider or an appropriate source

Components of E/M Services

• History *• Examination *• Medical Decision Making *• Counseling• Coordination of Care• Nature of Presenting Problem• Time

• * Key Components

History

• Four Types:• Problem Focused

• Expanded Problem Focused

• Detailed

• Comprehensive

• Components that determine the extent of history obtained:

• 1.Chief Complaint/History of Present Illness:• Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Signs and Symptoms

• 2. Review of Systems:• Constitutional, Eyes, Ears/Nose/Throat/Mouth, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,

Musculoskeletal, Integument, Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic

• 3. Past, Family, Social History:• Past History, Family History, Social History

After Determining which level of each history component is applicable, choose the overall level of history:

HPI + ROS + PFSH = Level of History

Brief N/A N/A Problem Focused

Brief Problem Pertinent N/A Expanded Problem Focused

Extended Extended Pertinent Detailed

Extended Complete Complete Comprehensive

Examination

• Four Types:

• Problem Focused –A limited examination of the affected body area or organ system.

• Expanded Problem Focused –A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed –An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

• Comprehensive –A general multi-system examination or a complete examination of a single organ system.

Examination

• Body areas• Head, including Face

• Neck

• Chest, including Breasts and Axilla

• Abdomen

• Genitalia, Groin, Buttocks

• Back

• Each Extremity

Examination

• Organ Systems• Eyes

• Ears, Nose, Throat, & Mouth

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Skin

• Neurological

• Psychiatric

• Hematological/Lymphatic/ Immunologic

Examination

• Constitutional: Measurement of any 3 of the following 7 vital signs:

• Sitting or Standing Blood Pressure

• Supine Blood Pressure

• Pulse Rate and Regularity

• Respiration Rate

• Temperature

• Height

• Weight

Examination

• General Appearance• Development

• Nutrition

• Deformities

• Body habitus

• Grooming

Examination

• Cardiovascular• Exam of the vascular system by observation

(swelling, vasoconstriction etc.), palpation (pulse, temperature, edema, tenderness) or auscultation (heart sounds, murmurs, bruits).

Examination (MSK elements)• Gait and Station

• Exam of joints, bones, muscles, and tendons of 4 of the following 6 areas:

• Head and Neck

• Spine, Ribs and Pelvis

• Right UE

• Left UE

• Right LE

• Left LE

Examination (MSK elements)

• Examination of a given area includes:• Inspection, percussion, palpation, with

notation of any misalignment, asymmetry, defects, tenderness, masses or effusions.

• Assessment of Range of Motion (ROM) noting any restriction, pain, crepitus, contracture, etc.

Examination (MSK elements)

• Assessment of Stability noting any joint fixation, laxity, subluxation, dislocation, etc.

• Assessment of Muscle noting strength, atrophy, spasm, abnormal movement, etc.

Examination (MSK elements)• Skin: Inspection and/or palpation of the skin

and subcutaneous tissue (scars, rashes, lesions, ulcers, etc.) in 4 of the following 6 areas:

• Head/Neck

• Trunk

• Right UE

• Left UE

• Right LE

• Left LE

Examination (MSK elements)

• Neurological & Psychiatric• Coordination and/or proprioception UE & LE

• Reflexes (deep tendon, pathological)

• Sensory (touch, proprioception)

• Mental Status (orientation to time/ place/person)

• Mood and Affect (depression, anxiety, agitation, etc.)

Medical Decision Making

The complexity of establishing a diagnosis and/or selecting a management option is measured by the following 3 elements:

• 1. The number of possible diagnoses and/or number of management options that must be considered

• 2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed

• 3. The risk of significant complications, morbidity and/or mortality, as well as co morbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) and possible management options

Medical Decision Making

• Four Types of Decision Making:• Straight Forward• Low Complexity• Moderate Complexity • High Complexity

• Determine the type of decision making by choosing which levels of risk qualify for each element of medical decision making. Two out of three elements must be met or exceeded to qualify for any given level of decision making.

Medical Decision Making

Number of DX Amount and/or Risk of Complications

Or Management + Complexity of Data+ and/or Morbidity or = Type of

Options to be Reviewed Mortality Decision Making

Minimal Minimal/None Minimal Straight Forward

Limited Limited/Low Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High HighComplexity

Office or other outpatient services New Patient 99201-99205

For a new patient, all three key components must be met or exceeded to qualify for a particular level of service. The

overall level of service is selected based on the performance and documentation of history, examination,

and medical decision making.

Office or other outpatient service Established Patient 99211-99215

For an established patient, two of the three key components must be met or exceeded to qualify for a particular level of service. The overall level of service is selected based on the

performance and documentation of history, examination, and medical decision making.

Preventive Services

• Extent and focus of the service largely depends on the age of the patient

• If an abnormality is encountered then a separate E/M service may be indicated

• Counseling and anticipatory guidance /risk factor reduction interventions

Preventive Services

• New patients• 99381: age under 1 year

• 99382: age 1-4 years

• 99383: age 5-11 years

• 99384: age 12-17 years

• 99385: age 18-39 years

• 99386: age 40-64 years

• 99387: age 65 years and over

Preventive Services

• Established patients• 99391: age under 1 year

• 99392: age 1-4 years

• 99393: age 5-11 years

• 99394: age 12-17 years

• 99395: age 18-39 years

• 99396: age 40-64 years

• 99397: age 65 years and over

Special E/M Services

• Work Related or Medical Disability Evaluations by Treating Physician (99455)

• Completion of medical history• Performance of examination• Formulation of diagnosis, assessment of

capabilities and stability, calculation of impairment

• Development of treatment plan• Completion of necessary documentation

Special E/M Services

• Work Related or Medical Disability Evaluations By Other Than Treating Physician (99456)

• Completion of medical history

• Performance of examination

• Formulation of diagnosis, assessment of capabilities and stability, calculation of impairment

• Development of treatment plan

• Completion of necessary documentation

ICD-9-CM (10)

• International Classification of Disease-Clinical Modification (ICD-CM) is a universally accepted coding nomenclature that defines patient diagnosis

• Providers place the appropriate ICD-9-CM code(s) on the CMS-1500 form in Box #21

• Always use accurate diagnosis codes and customize the diagnosis for each patient

• While patients may have similar conditions, each presents a unique clinical picture

ICD-9-CM

Documentation must support the diagnosis codes you use. For example, if you bill for an ankle adjustment, a diagnosis involving the ankle is required and it must be supported by documented examination findings

ICD-10-CM comes on-line October 1, 2015

Be Prepared

Diagnostic Examples

• Neurological• Radiculopathy (723.4, 724.4)

• Neuropathy (sciatica w/o discopathy 355.0)

• Headaches (784.0, tension 307.81, migraine 346.00)

• Structural• Degenerative Joint Disease (715.8)

• Degenerative Disc Disease (722.4, 722.51, 722.52)

• Spondylolisthesis (738.4)

Diagnostic Examples

• Last 2 digits indicate specific region• Functional

• Restricted Range of Motion (719.58)

• Deconditioning, muscle wasting (728.2)

• Soft Tissue• Myalgia, myofascial pain (729.1)

• Extremity• Bursitis (726.10* shoulder)

• Carpal Tunnel Syndrome (354.0)

• Meniscus injuries (717.3 medial, 717.4 lateral)

Telephone Evaluation Services • 99441 Telephone evaluation and management

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 or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

• 99442 11-20 minutes of medical discussion

• 99443 21-30 minutes of medical discussion

Telephone Evaluation Services

• These codes are used to report episodes of care initiated by an established patient or guardian of an established patient

• Bill E/M instead of these codes if the telephone service ends with a decision to see the patient within 24 hours/next available appointment or if the telephone call refers to an E/M service performed within the previous seven days or within the postoperative period of a procedure.

On-Line Evaluation

• 99444 Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communication network.

• Reportable services are those that include that physician’s timely response to a patient’s inquiry and require that the physician permanently store (electronically or in hard copy) the encounter.

Disability Evaluations

• Work Related or Medical Disability Evaluations by Treating Physician (99455)

• Completion of medical history

• Performance of examination

• Formulation of diagnosis, assessment of capabilities and stability, calculation of impairment

• Development of treatment plan

• Completion of necessary documentation

Disability Evaluations

• Work Related or Medical Disability Evaluations By Other Than Treating Physician (99456)• Completion of medical history

• Performance of examination

• Formulation of diagnosis, assessment of capabilities and stability, calculation of impairment

• Development of treatment plan

• Completion of necessary documentation

CMT

• The expected distribution of codes by Medicare is approximately:

• 98940: 35%

• 98941: 55%

• 98942: 10%

CMT

• 5 Spinal regions• Cervical including atlanto-occipital

• Thoracic including posterior ribs

• Lumbar

• Sacrum

• Pelvis including SI joints

CMT

• 98940: One to two spinal regions

• 98941: Three to four spinal regions

• 98942: Five spinal regions

CMT

• Extraspinal regions• Head including TMJ

• Upper extremities

• Lower extremities

• Anterior ribs

• Abdomen

CMT

• 98943, 1 or more extra-spinal regions

• Correlate:• Symptoms

• Exam findings

• Diagnosis

• Treatment

• Documentation

CMT Work Valuation

• Pre-service

• Intra-service

• Post-service

CMT Documentation

• Subjective record of the patient’s complaint.

• Physical findings to support manipulation in a region.

• Assessment of change in a patient’s condition, as appropriate.

• Record of specific segments manipulated.

Reporting E/M with CMT

• You may bill a separate E/M code on the same day as a CMT in the following situations:• A new patient visit.

• An established patient with a new condition.

• A new injury, re-injury, aggravation, exacerbation, or re-evaluation to determine if a change in treatment plan is necessary.

• Reporting of E/M services with CMT should be supported by appropriate documentation.

Physical Medicine Services

• Supervised modalities• Do not require one-on-one contact by the

provider

• May be billed only once per encounter

• Code 97012 (mechanical traction) is an example of a supervised modality

Physical Medicine Services• Constant attendance procedures

• Require direct one-on-one patient contact by provider.

• Billed once per 15-minute unit.

• Code 97032 (manual electrical stimulation) requires constant attendance.

• Code 97035 (ultrasound) also requires one-on-one provider attendance.

Therapeutic Exercises 97110• Used to develop strength and

endurance, range of motion, and flexibility (one parameter).

• Examples• Treadmill for endurance• Isokinetic exercise for ROM• Lumbar stabilization exercises for strength• Gym ball for flexibility

Neuromuscular Reeducation 97112• Used when describing those activities that

affect:

• Movement

• Proprioception

• Balance

• Coordination

• Kinesthetic sense

• Posture

Therapeutic Activities (97530)• AKA: Kinetic Activities.

• Used when multiple parameters are involved, including balance, strength, and range of motion.

• Must be related to a functional activity with direct functional improvement expected.

• Billed in 15-minute increments.

Massage (97124)

• Massage is a passive procedure used for restorative effect.

• Massage includes effleurage, petrissage, and/or tapotement (stroking, compression, and/or percussion).

• It is an independent procedure from CMT and is considered separate and distinct.

Manual Therapy (97140)

• Includes soft tissue and joint mobilization, manual traction, trigger point therapies, passive range of motion, myofascial release, etc.

• Add -59 modifier when reported with CMT

Temporary S Codes

• “Temporary national codes (non-Medicare). The S codes are used by the Blue Cross Blue Shield Association and the Health Insurance Association of America to report drugs, services and supplies for which there are no national codes but for which codes are needed by the private sector to implement policies, programs or claims processing. They are for meeting the particular needs of the private sector.”

Temporary S Codes

• Verify with insurers to determine if they will accept the S codes

• S9090--Vertebral axial decompression, per session

• AMA CPT has indicated that CPT 97012 should be billed for verterbral axial decompression

• S8948--(Application of a modality [requiring constant provider attention] to one or more areas; low-level laser; each 15 minutes.

Unlisted Modalities(97039)

• When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (e.g. procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time, effort and equipment necessary to provide the service.

• 97039--Hydro-Bed Therapy

• 97039--Infratonic

Acupuncture

• 97810• Acupuncture, one or more needles; without electrical

stimulation, initial 15 minutes.

• 97811• Acupuncture, one or more needles; without electrical

stimulation, each additional 15 minutes.

• 97813• Acupuncture, one or more needles; with electrical

stimulation, initial 15 minutes.

• 97814• Acupuncture, one or more needles; with electrical

stimulation, additional 15 minutes.

Acupuncture

• Reported in 15-minute increments.

• Time based on direct one-on-one contact with the patient, not duration of needle(s) placement.

• Reported with or without electrical stimulation.

• E/M may be reported separately.

Functional Testing

• Manual Muscle Testing (95831-95834)

• Range of Motion Testing (95851-95852)

• Physical Performance Testing (97750)

• Testing and measurements are taken and compared to a standardized grading scale.

• A formal written and signed report of the findings is made, including the comparison analysis.

Imaging

• Radiology Codes – normally global (both professional and technical component)

• Professional Component -26 modifier

• E/M Component

• Consultation on X-ray made elsewhere

Imaging

• When you are the treating physician, use the appropriate E/M code (e.g., 99212).

• When you are not the treating physician, you can bill for re-reading x-rays with the code 76140.

Modifiers

• -25: Separately identifiable E/M service

• -59: Distinct procedural services

• -76: Repeat procedure by the same physician

Up-coding, Down-Coding and Bundling• ACA and many other national associations

have formal position statements that oppose bundling and down coding that is inconsistent with CPT billing intent.

• ACA Policy can be found in the ACA Chiropractic Coding and Compliance Manual.

• You are entitled to bill according to CPT intent for your services.

• If codes are bundled or down coded inappropriately, use this policy to appeal the claim.

Up-Coding

• Up coding is an intentional act by a provider to inflate a code to a higher level (e.g., reporting 99204 when 99203 would be more appropriate).

• This should be avoided and may be considered evidence of fraud.

Coding Abuse

• On a final note, make coding work for you by following the recommendations of experts

• Don’t get caught up in schemes that sound too good to be true (vendor suggestions)

• Don’t be part of the small percentage of providers who abuse the reimbursement system and cast suspicion on the entire profession

• Consistent patterns of incorrect coding can trigger investigations and recoupment efforts

• Data mining/retrospective reviews by insurers can show a business pattern of inappropriate code use which can be interpreted as fraud

ACA Template Appeal Letters• If you use the E/M codes and modifiers

correctly and are still denied, here’s what you can do.

• Refer to the E/M Template Letter in the ACA Coding and Compliance Manual.

• This will alert the insurer to correct policy and is an excellent appeals mechanism, if needed.

THE END