coding 2015 challenges and opportunities coding 2015 challenges and opportunities richard h. tuck,...

Coding 2015Coding 2015Challenges and OpportunitiesChallenges and Opportunities

Richard H. Tuck, MD,FAAPRichard H. Tuck, MD,FAAP© 10/1/14© 10/1/14

Richard Tuck

IMPORTANCE OF ACCURATE IMPORTANCE OF ACCURATE APPROPRIATE CODINGAPPROPRIATE CODING

INCREASED PAYMENTINCREASED PAYMENT

DECREASED LIABILITYDECREASED LIABILITY

IMPROVED INFORMATION FLOWIMPROVED INFORMATION FLOW

ICD-10-CMICD-10-CM

READY OR NOT ? !READY OR NOT ? !

October 1, 2015October 1, 2015

ICD-10-CMICD-10-CM

Will become effective Will become effective October 1, 2015 October 1, 2015 – NO EXCEPTIONS NO EXCEPTIONS if you are a covered entity under if you are a covered entity under

HIPAA.HIPAA.– Currently there is a freeze on new Currently there is a freeze on new ICD-9-CMICD-9-CM and and

ICD-10-CMICD-10-CM codes to prepare for the changeover. codes to prepare for the changeover.

Significant changeSignificant change

ICD-9-CM ICD-9-CM →→ (Diagnosis) (Diagnosis) 5 characters5 characters14,000 codes14,000 codes

ICD-9-CM ICD-9-CM →→(Procedure)(Procedure)5 characters5 characters4,000 codes4,000 codes

ICD-10-CMICD-10-CM7 characters7 characters>68,000 codes>68,000 codes

ICD-10-PCSICD-10-PCS(Inpatient)(Inpatient)7 characters7 characters>72,000 codes>72,000 codes

Value to ProvidersValue to Providers

More accurately reflects the acuity of the patient More accurately reflects the acuity of the patient populationpopulation

More accurately reflects application of advances in More accurately reflects application of advances in medical knowledgemedical knowledge

Improved visibility into population health/risksImproved visibility into population health/risks Better defined and automated referrals and approvalsBetter defined and automated referrals and approvals More detail for preauthorization medical reviewMore detail for preauthorization medical review

Enhanced Care ManagementEnhanced Care Management+ ? Payment+ ? Payment

More detail to support effective engagement and More detail to support effective engagement and interventionsinterventions

Enhanced knowledge sharing, communication, Enhanced knowledge sharing, communication, and coordinationand coordination

Improved analytics and complianceImproved analytics and compliance Better identification of gaps in careBetter identification of gaps in care

InnovationInnovation

Supports:Supports: Patient Centered Primary CarePatient Centered Primary Care Clinical Integration StrategiesClinical Integration Strategies Accountable Care OrganizationsAccountable Care Organizations Value Based ReimbursementValue Based Reimbursement

Using and Reporting Using and Reporting ICD-9 (10)-CM ICD-9 (10)-CM CodesCodes

Code to the highest degree of specificity

Code to the highest degree of certainty for the encounter such assymptoms, signs, abnormal test results,

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

List the ICD code that is identified as the main reason forthe service first. Next list any current coexisting conditions.

Chronic disease treated on an ongoing basis may be coded

Do not code for conditions that were previously treated and nolonger exist

ICD-10-CM Code Format and StructureICD-10-CM Code Format and Structure S60S60 Superficial injury of wrist, hand and Superficial injury of wrist, hand and fingers*fingers* S60.4S60.4 Other superficial injuries of Other superficial injuries of otherother fingers fingers S60.45S60.45 Superficial Superficial foreign body [splinter]foreign body [splinter] of of

fingers**fingers** S60.451S60.451 Superficial foreign body [splinter] of Superficial foreign body [splinter] of left left

indexindex finger finger S60.451AS60.451A Superficial foreign body [splinter] Superficial foreign body [splinter] of left of left

index finger, index finger, initial encounterinitial encounter****** Required to use the 7 digit code for this conditionRequired to use the 7 digit code for this condition

»*category, **subcategory, ***code*category, **subcategory, ***code

How Do Codes Translate How Do Codes Translate ICD-9-CM ICD-9-CM ICD-10-CM? ICD-10-CM?

ICD-9-CM ICD-9-CM ICD-10-CM ICD-10-CM

Some codes will have the same wording between the 2 Some codes will have the same wording between the 2 codes sets and basically codes sets and basically ““crosswalkcrosswalk”” over over

ICD-9-CMICD-9-CM toto ICD-10-CMICD-10-CM

003.21 Salmonella meningitis003.21 Salmonella meningitis == A02.21 Salmonella meningitisA02.21 Salmonella meningitis

745.2 Tetralogy of Fallot745.2 Tetralogy of Fallot == Q21.3 Tetralogy of FallotQ21.3 Tetralogy of Fallot


Some codes wonSome codes won’’t match because of changes in t match because of changes in definitions in ICD-10-CMdefinitions in ICD-10-CM

ICD-9-CMICD-9-CM toto ICD-10-CMICD-10-CM

764.0 "Light-for-dates" without 764.0 "Light-for-dates" without mention of fetal malnutrition mention of fetal malnutrition birthweight 2,500 grams and birthweight 2,500 grams and overover

≠≠ No diagnosis for infant with No diagnosis for infant with this birthweightthis birthweight code set is for weights code set is for weights <2500 grams<2500 grams


When there is more specificity in I-10, there may be When there is more specificity in I-10, there may be multiple codes to describe the condition or disease. multiple codes to describe the condition or disease. Increased physician documentation will be vitalIncreased physician documentation will be vital

ICD-9-CM SourceICD-9-CM Source toto ICD-10-CM TargetICD-10-CM Target

599.72 Microscopic 599.72 Microscopic hematuriahematuria

≈≈ R31.1 Benign essential R31.1 Benign essential microscopic hematuriamicroscopic hematuria

599.72 Microscopic 599.72 Microscopic hematuriahematuria

≈≈ R31.2 Other microscopic R31.2 Other microscopic hematuriahematuria


When ICD-10-CM contains a combination code, it will When ICD-10-CM contains a combination code, it will relate back to 2 distinct ICD-9-CM codesrelate back to 2 distinct ICD-9-CM codes

What used to require 2 or more codes, now only requires What used to require 2 or more codes, now only requires a single codea single code

ICD-10-CM SourceICD-10-CM Source toto ICD-9-CM TargetICD-9-CM Target

R65.21 Severe sepsis with R65.21 Severe sepsis with septic shockseptic shock

≈≈ 995.92 Severe sepsis995.92 Severe sepsis

andand

785.52 Septic shock785.52 Septic shock

Otitis Media ICD-10Otitis Media ICD-10 Specific VariablesSpecific Variables

– AcuityAcuity» Acute/subacute vs. chronicAcute/subacute vs. chronic

– Specific TypeSpecific Type» Serous, mucoid, suppurative, sanguineousSerous, mucoid, suppurative, sanguineous

– Rupture of eardrumRupture of eardrum– LateralityLaterality

» Right, Left, BilateralRight, Left, Bilateral– RecurrenceRecurrence

Terminology mattersTerminology matters Acute suppurative otitis media without spontaneous Acute suppurative otitis media without spontaneous

rupture of ear drumrupture of ear drum– H66.001, right earH66.001, right ear– H66.002, left earH66.002, left ear– H66.003, bilateralH66.003, bilateral– H66.004, recurrent, right earH66.004, recurrent, right ear– H66.005, recurrent, left earH66.005, recurrent, left ear– H66.006, recurrent, bilateralH66.006, recurrent, bilateral– H66.007, recurrent, unspecified earH66.007, recurrent, unspecified ear– H66.009, unspecified earH66.009, unspecified ear

Asthma Documentation ImprovedAsthma Documentation Improved

State of the asthmaState of the asthma

Uncomplicate, acute exacerbation, statusUncomplicate, acute exacerbation, status FrequencyFrequency

Mild intermittentMild intermittent

Mild, moderate, severe persistentMild, moderate, severe persistent Triggers Triggers

Ex tobacco smokeEx tobacco smoke

Asthma ICD-10Asthma ICD-10 J45.2xJ45.2x Mild intermitentMild intermitent J45.3xJ45.3x Mild persistentMild persistent J45.4xJ45.4x Mod persistentMod persistent J45.5xJ45.5x Severe persistentSevere persistent

X =X =– 0 Uncomplicated0 Uncomplicated– 1 With acute exacerbation1 With acute exacerbation– 2 With status asthmaticus2 With status asthmaticus

Z 77.22 Exposure to tobacco smokeZ 77.22 Exposure to tobacco smoke

Case ScenarioCase Scenario You see an est pt, 4 year old boy, with a hx of asthma. Exp Prob You see an est pt, 4 year old boy, with a hx of asthma. Exp Prob

Focused Hx: Intermittent night time cough, with occasional episodes Focused Hx: Intermittent night time cough, with occasional episodes of wheezing, relieved using an albuterol MDI; No restrictions of of wheezing, relieved using an albuterol MDI; No restrictions of activity noted FHx: No others ill; SHx Parents smoke “outside”activity noted FHx: No others ill; SHx Parents smoke “outside”

Vitals wnl, pulse ox 98%; No respiratory distress; Detailed exam: Vitals wnl, pulse ox 98%; No respiratory distress; Detailed exam: rare expiratory wheezes. You make a diagnosis of asthma using rare expiratory wheezes. You make a diagnosis of asthma using current asthma dx guidelines.current asthma dx guidelines.

You discuss the diagnosis in detail, including management of asthma You discuss the diagnosis in detail, including management of asthma using rescue (albuterol) and controller (inhaled steroid) MDIs. The use using rescue (albuterol) and controller (inhaled steroid) MDIs. The use of MDI’s with a spacer is discussed, demonstrated, and documented.of MDI’s with a spacer is discussed, demonstrated, and documented.

Followup visit is scheduled in two weeks. Followup visit is scheduled in two weeks.

Asthma Scenario CodingAsthma Scenario Coding

CPTCPT– E/ME/M 9921499214– Pulse OxPulse Ox 9476094760– MDI TeachingMDI Teaching 94664-5994664-59

ICD-9ICD-9– 493.00493.00 Asthma, Childhood w/o statusAsthma, Childhood w/o status

ICD-10ICD-10– J45.21J45.21 Asthma, Mild Intermittent, Asthma, Mild Intermittent,

ExacerbationExacerbation– Z77.22Z77.22 Exposure to tobacco smokeExposure to tobacco smoke

DermatitisDermatitis

Atopic/eczematousAtopic/eczematous– FlexuralFlexural L20.82L20.82– InfantileInfantile L20.83L20.83– Ear Ear H60.541- H60.543H60.541- H60.543 (laterality) (laterality)– EyelidEyelid H01.131- H01.135H01.131- H01.135 (laterality) (laterality)

Due to substances taken internallyDue to substances taken internally– Generalized skin eruptionGeneralized skin eruption L27.0L27.0– Localized skin eruptionLocalized skin eruption L27.1L27.1


DiaperDiaper

– Erythema to dermatitisErythema to dermatitis L22L22Dry skinDry skin L85.3L85.3SeborrheicSeborrheic

– Cradle capCradle cap L21.0L21.0

– Seborrheic infantileSeborrheic infantile L21.1L21.1


Contact dermatitisContact dermatitis– AllergicAllergic L23.1 – L23.9L23.1 – L23.9

» Adhesive, cosmetics, drugs, food, metals, Adhesive, cosmetics, drugs, food, metals, plants (poison ivy, etc.)plants (poison ivy, etc.)

» EarEar H60.531-3H60.531-3 Eyelid H01.111-5Eyelid H01.111-5– IrritantIrritant L25.3 – L24.9L25.3 – L24.9

» Cement, cosmetics, drugs, etc.Cement, cosmetics, drugs, etc.– Not specified as Allergic or Irritant L25.3 – L25.9Not specified as Allergic or Irritant L25.3 – L25.9

» Cement, dyes, foodCement, dyes, food

Symptom/Compliant Based CodingSymptom/Compliant Based Coding

A 3 yo child presents with a cough, fever and A 3 yo child presents with a cough, fever and vomiting. It appears the symtoms are due to a viral vomiting. It appears the symtoms are due to a viral process, but this is not a firm diagnosis.process, but this is not a firm diagnosis.

Code for the symptoms and complaints:Code for the symptoms and complaints:

ICD-9ICD-9 ICD-10ICD-10– FeverFever 780.60780.60 R50.9R50.9– CoughCough 786.2786.2 R05R05– VomitingVomiting 787.03787.03 R11.11 (w/o nausea)R11.11 (w/o nausea)

R11.10 (unspecified)R11.10 (unspecified)

““Inherent” conditionsInherent” conditions

Do not separately code for presenting problems or Do not separately code for presenting problems or findings inherent to a conditionfindings inherent to a condition– Vomiting and diarrhea are inherent in acute Vomiting and diarrhea are inherent in acute

gastroenteritis, Do not code separatelygastroenteritis, Do not code separately– Ear pain (otalgia) is inherent in otitis mediaEar pain (otalgia) is inherent in otitis media

Do code for conditions not inherent in a diagnosisDo code for conditions not inherent in a diagnosis– Hypoxia is not inherent in pneumoniaHypoxia is not inherent in pneumonia

? Urinary Tract Infection? Urinary Tract Infection

An 8 yo girl presents with 2 days of urgency and An 8 yo girl presents with 2 days of urgency and burning on urination. There are no other burning on urination. There are no other complaints and the exam is normal. An office complaints and the exam is normal. An office urinalysis is indeterminate and a culture is sent.urinalysis is indeterminate and a culture is sent.

Code only for the symptomsCode only for the symptoms

ICD-9ICD-9 ICD-10ICD-10

– Dysuria Dysuria 788.1788.1 R30.0R30.0

– Urinary frequencyUrinary frequency 788.63788.63 R39.15R39.15

NeonateNeonate Neonatal period is the first 28 days of lifeNeonatal period is the first 28 days of life Neonatal codes should be used for conditions in this Neonatal codes should be used for conditions in this

age groupage group

– Newborn vomitingNewborn vomiting P92.01-P92.09 P92.01-P92.09

– Newborn seizureNewborn seizure P90 P90 May be used after the neonatal period if the condition May be used after the neonatal period if the condition

affects the visitaffects the visit

– Infant of substance abusing mother P04.3-P04.49Infant of substance abusing mother P04.3-P04.49

– Bronchopulmonary dysplasiaBronchopulmonary dysplasia P27.1 P27.1

Z-codes (The New “V” Codes)Z-codes (The New “V” Codes)

Encounter for healthcare examsEncounter for healthcare exams Must be recognized by third party payorsMust be recognized by third party payors May be used as primary diagnosisMay be used as primary diagnosis

Preventive Medicine/Vaccine ICD-10Preventive Medicine/Vaccine ICD-10 CodingCoding

ICD-10 effective October 1, 2015ICD-10 effective October 1, 2015 Preventive CarePreventive Care

V20.2 crosswalks: V20.2 crosswalks: Z00.129Z00.129 w/o abnl findings w/o abnl findings Z00.121Z00.121 with abnl findings with abnl findings

Vaccine product V codes all crosswalk to one ICD-10 code: Vaccine product V codes all crosswalk to one ICD-10 code: Z23Z23, encounter for immunization, encounter for immunization

Vaccination not carried out (V64.00- V64.09) crosswalk Vaccination not carried out (V64.00- V64.09) crosswalk with with Z28.20-Z28.9 Z28.20-Z28.9 codes codes

Vaccines not givenVaccines not given

Z28.20 Z28.20 Due to patient decision for unspecified Due to patient decision for unspecified reason reason

Z28.21 Z28.21 Due to patient refusal Due to patient refusal Z28.29 Z28.29 Due to patient decision for other reason Due to patient decision for other reason Z28.81 Z28.81 Due to patient having had the disease Due to patient having had the disease Z28.82 Z28.82 Due to caregiver refusal Due to caregiver refusal Z28.89 Z28.89 For other reason For other reason Z28.9 Z28.9 For unspecified reason For unspecified reason

Other Routine Health VisitsOther Routine Health Visits

Z01.818 Z01.818 Pre-operative examinationPre-operative examination Z02.0 Z02.0 School physicalsSchool physicals Z02.5 Z02.5 Sport physicalsSport physicals Z02.82 Z02.82 Pre-adoption examPre-adoption exam

Overweight/obesityOverweight/obesity Add BMI code if concern about:Add BMI code if concern about:


– UnderweightUnderweight 783.22783.22 R63.6R63.6– OverweightOverweight 278.02278.02 E66.3E66.3– ObesityObesity 278.00278.00 E66.01 E66.01 (excessive calories)(excessive calories)

E66.09 E66.09 (other obesity)(other obesity)

E66.8 E66.8 (unspecified)(unspecified)

Diet surveillance and counselingDiet surveillance and counseling

V65.3V65.3 Z71.3Z71.3

Overweight/obesityOverweight/obesity

– Z68.51 pediatric BMI <5Z68.51 pediatric BMI <5thth% for age% for age

– Z68.52 pediatric BMI 5Z68.52 pediatric BMI 5thth<85<85thth% for age% for age

– Z68.53 pediatric BMI 85Z68.53 pediatric BMI 85thth–<95–<95thth% for age% for age

– Z68.54 pediatric BMI ≥95Z68.54 pediatric BMI ≥95 thth% for age% for age

Healthcare ServicesHealthcare Services

Z09 Z09 Follow-up exam, after treatmentFollow-up exam, after treatment– Use additional code to identify any applicable history Use additional code to identify any applicable history

of disease code (Z86.-. Z87.-)of disease code (Z86.-. Z87.-) Z48.02 Z48.02 Suture removal Suture removal Z48.817 Post I&D aftercareZ48.817 Post I&D aftercare Z71.0 Z71.0 Parent (family) conferenceParent (family) conference Z71.3 Z71.3 Diet management (for obesity)Diet management (for obesity) Z76.81 Z76.81 Parents pre-birth or pre-adoption visitParents pre-birth or pre-adoption visit

Follow-up VisitFollow-up Visit

A 2 yo is seen for a f/u visit after completing a A 2 yo is seen for a f/u visit after completing a course of antibiotics for otitis media. The ears are course of antibiotics for otitis media. The ears are normal to examination and the child is eating and normal to examination and the child is eating and acting well.acting well.


Follow-up after RxFollow-up after Rx V67.59V67.59 Z09Z09 PMHx respiratory diseasePMHx respiratory disease Z86.09Z86.09 Code condition if still present or otherCode condition if still present or other

What if nothing’s wrong?What if nothing’s wrong?

When unable to find specific conditions then code for When unable to find specific conditions then code for ““ Observation (exam) for:Observation (exam) for:”” – following transport accident (Z04.1)following transport accident (Z04.1)– for work (school) related incident (Z04.2)for work (school) related incident (Z04.2)– for alleged child rape or sexual assault (Z04.42)for alleged child rape or sexual assault (Z04.42)– for suspected child abuse or neglect (Z04.72)for suspected child abuse or neglect (Z04.72)– for alleged assault (Z04.72)for alleged assault (Z04.72)– for other suspected disease or condition ruled out for other suspected disease or condition ruled out

(Z03.89)(Z03.89)– for suspected neonatal condition (P00.-)for suspected neonatal condition (P00.-)

TransitionTransition

Encounters that take place Encounters that take place on or after October 1, 2015on or after October 1, 2015 are reported with ICD-10-CM codesare reported with ICD-10-CM codes

Encounters that take place Encounters that take place before October 1, 2015before October 1, 2015 are are reported with ICD-9-CM codesreported with ICD-9-CM codes

You will have to run simultaneous systems of ICD-9 and You will have to run simultaneous systems of ICD-9 and ICD-10 until all your claims from before October 1, 2015 ICD-10 until all your claims from before October 1, 2015 have clearedhave cleared

ICD-10 ImplementationICD-10 ImplementationBusiness and Practice ConsiderationsBusiness and Practice Considerations

Touches every area of the PracticeTouches every area of the Practice Everyone needs some basic trainingEveryone needs some basic training Coder and billing staff education to include Coder and billing staff education to include

hands-on use of ICD-10-CM and PCS code setshands-on use of ICD-10-CM and PCS code sets

How Do Codes Translate How Do Codes Translate ICD-9-CM ICD-9-CM ICD-10-CM? ICD-10-CM?

ICD-10 GEMsICD-10 GEMs

General Equivalence MappingsGeneral Equivalence Mappings Tool for converting ICD-9-CM databases to ICD-Tool for converting ICD-9-CM databases to ICD-

10-CM or ICD-10-PCS10-CM or ICD-10-PCS Backward and forward mappingBackward and forward mapping Move to coding books and encoder systems Move to coding books and encoder systems

October 1, 2015October 1, 2015 Free GEMS download: Free GEMS download:

www.cdc.gov/nchs/icd/icd10cm.htm#icd2014www.cdc.gov/nchs/icd/icd10cm.htm#icd2014

Analyze Your Top DxsAnalyze Your Top Dxs

By frequencyBy frequency By revenueBy revenue Know replacement codesKnow replacement codes

Include additional details on Include additional details on

SuperbillSuperbill

EMREMR

Train staffTrain staff


Download GEMS freeDownload GEMS free Convert your top diagnosis codesConvert your top diagnosis codes

– Start with the top tenStart with the top ten

– Complete the top twenty to thirtyComplete the top twenty to thirty Conduct chart auditsConduct chart audits End to End testing is the ultimate testEnd to End testing is the ultimate test

– Send claims – Receive paymentSend claims – Receive payment

Determine Impact on Your SystemsDetermine Impact on Your Systems

Update superbills, charge sheetsUpdate superbills, charge sheets

2-4 hours2-4 hours Add additional details in HERAdd additional details in HER Train staff on added detail requirements 2-8 hoursTrain staff on added detail requirements 2-8 hours

Outpatient Coders 16 hoursOutpatient Coders 16 hours Certified coders must pass test to maintain certification Certified coders must pass test to maintain certification Train physiciansTrain physicians

8-12 hours8-12 hours


Y 2 K ??Y 2 K ?? Initial Loss of Productivity – Up to 40% !Initial Loss of Productivity – Up to 40% ! Line of Credit to support the TransitionLine of Credit to support the Transition

– CMS recommends 6 mos line of credit CMS recommends 6 mos line of credit Minimum 30 –60 days cash reserveMinimum 30 –60 days cash reserve

– AMA estimates cost of $10,000 per physicianAMA estimates cost of $10,000 per physician

– May need to hire an additional coderMay need to hire an additional coder Hardware and software impactHardware and software impact

7 Step Planning and Implementation7 Step Planning and Implementation PLAN – Complete by Winter 2014PLAN – Complete by Winter 2014

Establish structure and leadershipEstablish structure and leadership

Physician championPhysician champion

Project manager / TeamProject manager / Team COMMUNICATE – Ongoing with all “stakeholders”COMMUNICATE – Ongoing with all “stakeholders”

Education and Planning with confidenceEducation and Planning with confidence IMPACT ASSESSMENT -NowIMPACT ASSESSMENT -Now

Business and policy impactsBusiness and policy impacts

Technology impactsTechnology impacts

7 Step Planning and Implementation7 Step Planning and Implementation IMPLEMENTATION – To followIMPLEMENTATION – To follow

Identification of systems issuesIdentification of systems issues

Preparation for trainingPreparation for training TESTING – Early 2015TESTING – Early 2015

Vendors, payers, billing companiesVendors, payers, billing companies BUDGETING – Early 2015BUDGETING – Early 2015

Financial Impact / Line of CreditFinancial Impact / Line of Credit TRANSITION – Summer 2015TRANSITION – Summer 2015

Go live environment for October 1, 2015Go live environment for October 1, 2015

PHYSICIANS:PHYSICIANS:DO IT FOR ME !DO IT FOR ME !

Detailed Documentation Is CriticalDetailed Documentation Is Critical

Tell the Story with DocumentationTell the Story with Documentation

Coder/Biller cannot make a DiagnosisCoder/Biller cannot make a Diagnosis

Do Your Part !Do Your Part !

How Your Performance is Measured How Your Performance is Measured How You Get Paid How You Get Paid

You are Ultimately Responsible ! You are Ultimately Responsible !

Transition: What you can do Transition: What you can do NOWNOW ? ? Encourage physicians to document and use more specific Encourage physicians to document and use more specific

codes codes – Especially those who tend to use unspecified codes or Especially those who tend to use unspecified codes or

whose documentation leads to an whose documentation leads to an ““unspecifiedunspecified”” code code Work with those physicians on their documentation and Work with those physicians on their documentation and

in areas where you know more documentation is needed in areas where you know more documentation is needed (e.g. Otitis Media)(e.g. Otitis Media)

Remember that all HIPAA covered entities are required Remember that all HIPAA covered entities are required to adhere to the transition to ICD-10-CMto adhere to the transition to ICD-10-CM– So do you! So do you!

Transition: What can you do Transition: What can you do THENTHEN??

Communicate with everyone!Communicate with everyone! Internal system design and developmentInternal system design and development Work with system vendorsWork with system vendors Policy change developmentPolicy change development Develop education and training planDevelop education and training plan Work with physicians and clinical staff on documentationWork with physicians and clinical staff on documentation Plan for a coding process slow downPlan for a coding process slow down Check commercial payors statusCheck commercial payors status GO LIVE – implementation complianceGO LIVE – implementation compliance

ICD-10-CM ICD-10-CM ++

Leverage your investmentLeverage your investment Move beyond mere compliance to achieve Move beyond mere compliance to achieve

strategic advantagestrategic advantage

Thanksgiving ICD-10 !Thanksgiving ICD-10 !

Y93.63 Activity Cooking and BakingY93.63 Activity Cooking and Baking W26.0 Contact with knifeW26.0 Contact with knife W61.42W61.42 Struck by TurkeyStruck by Turkey W71.43 Pecked by TurkeyW71.43 Pecked by Turkey W61.49W61.49 Other contact with TurkeyOther contact with Turkey W21.01W21.01 Struck by FootballStruck by Football

AAP Coding ResourcesAAP Coding ResourcesICD-10ICD-10

Principles of Pediatric ICD-10-CM Coding Principles of Pediatric ICD-10-CM Coding Pediatric Code Crosswalk: ICD-9-CM to ICD-10-CMPediatric Code Crosswalk: ICD-9-CM to ICD-10-CM ICD-10-CM Implementation Set for October 1, 2015ICD-10-CM Implementation Set for October 1, 2015

– Small and Medium PracticesSmall and Medium Practices

Large PracticesLarge Practices» Checklists for PlanningChecklists for Planning» TimelineTimeline» Implementation GuidesImplementation Guides

– Communication Plan for External ResourcesCommunication Plan for External Resources

AAP Coding ResourcesAAP Coding ResourcesICD-10 WebinarsICD-10 Webinars

ICD-10-CM, June 25, 2013: Postponed, Not canceled! ICD-10-CM, June 25, 2013: Postponed, Not canceled! Jeff Linzer, MD, FAAPJeff Linzer, MD, FAAP

Preparing for ICD-10 Implementation: Business and Preparing for ICD-10 Implementation: Business and Practice Considerations, January 13, 2014Practice Considerations, January 13, 2014

ICD-10-CM Coding: Part I, February 11, 2014 ICD-10-CM Coding: Part I, February 11, 2014 Jeff Linzer, MD, FAAP Jeff Linzer, MD, FAAP

ICD-10-CM Coding: Part II, March 25, 2014 ICD-10-CM Coding: Part II, March 25, 2014 Jeff Linzer, MD, FAAPJeff Linzer, MD, FAAP

CPT CodingCPT CodingThree Basic Principles of UseThree Basic Principles of Use

1. Physician should select diagnosis and procedure codes Coding confirmed by the “coding team”

2. Document patient services to support codesGood Care and Compliance

3. Use separate codes for different encounters

EM ESTABLISHED OFFICE- EM ESTABLISHED OFFICE- ExpectedExpected

05

1015

2025

3035

4045

50

EM EST OFFICE

9921199212992139921499215

EM ESTABLISHED OFFICE- EM ESTABLISHED OFFICE- ActualActual

0

10

20

30

40

50

60

EM EST OFFICE

9921199212992139921499215

EM ESTABLISHED OFFICE- EM ESTABLISHED OFFICE- Real PediatricsReal Pediatrics

0

5

10

15

20

25

30

35

40

EM EST OFFICE

9921199212992139921499215

EM ESTABLISHED OFFICE- EM ESTABLISHED OFFICE- SpecialitySpeciality

0

5

10

15

20

25

30

35

EM EST OFFICE

9921199212992139921499215

E/M PaymentsE/M Payments2014 Medicare2014 Medicare

9920199201 $43.35$43.35 9921199211 $20.06$20.06 9920299202 $74.51$74.51 9921299212 $43.70$43.70

9920399203 $108.18$108.18 9921399213 $73.08$73.08 9920499204 $166.22$166.22 9921499214

$107.83$107.83 9920599205 $207.06$207.06 9921599215

$144.37$144.37

Auditing / DocumentationAuditing / Documentation

95, 97 Guidelines95, 97 Guidelines Code to meet your documentationCode to meet your documentation If itIf it’’s not in the chart, it wasns not in the chart, it wasn’’t donet done Templates/ Clinical formsTemplates/ Clinical forms Computer Assists Electronic Computer Assists Electronic

medical recordsmedical records Beware of Beware of ““Documentation UpcodingDocumentation Upcoding”” Must Must

be be medically necessarymedically necessary ! !

Audit Friendly DocumentationAudit Friendly Documentation

Vital Signs (3 of Ht Wt BP RR HR Temp) Vital Signs (3 of Ht Wt BP RR HR Temp) SOAP SOAP formatformat

CC: chief complaintCC: chief complaint HPI: History of present illnessHPI: History of present illness PFSH: Past, Family, Social HistoryPFSH: Past, Family, Social History ROS: Review of SystemsROS: Review of Systems Impression/Plan (Medical Decision Making)Impression/Plan (Medical Decision Making)

– DDx , Tests, Treatment, PrescriptionsDDx , Tests, Treatment, Prescriptions– Counseling/coordination of careCounseling/coordination of care

TimeTime - Note time of encounter - Note time of encounter Total Time/ Time Counseling-Coordinating care Total Time/ Time Counseling-Coordinating care

Evaluation and Management CodesEvaluation and Management Codes7 Components7 Components

The The ““SCIENCESCIENCE”” of Coding of Coding KeyKey

– HistoryHistory– ExaminationExamination– Medical Decision MakingMedical Decision Making

ContributoryContributory– CounselingCounseling– Coordination of CareCoordination of Care– Nature of Presenting ProblemNature of Presenting Problem

ExplicitExplicit– Time – Only to assist physician in selectionTime – Only to assist physician in selection

HistoryHistory

TypeType HPIHPI ROSROS PFSHPFSH

ProblemProblem

Focused (212)Focused (212)

Brief (1-3)Brief (1-3) N/AN/A N/AN/A

ExpandedExpanded

ProblemProblem

Focused (213)Focused (213)

Brief (1-3)Brief (1-3) Brief (1)Brief (1) N/AN/A

Detailed (214) Detailed (214)

ExtendedExtended

(4+)(4+)

ExtendedExtended

(2-9)(2-9)

PertinentPertinent

(1)(1)

CompreCompre

hensive (215)hensive (215)

ExtendedExtended

(4+)(4+)

CompleteComplete

(10+)(10+)

CompleteComplete

(2/3 or 3/3)(2/3 or 3/3)

ExaminationExamination Problem Focused Problem Focused (212)(212)

– Limited to affected body area or organ systemLimited to affected body area or organ system– 1 body area / organ system1 body area / organ system

Expanded Problem Focused (213)Expanded Problem Focused (213)– Affected body area or organ system Affected body area or organ system and and other symptomatic or related organ other symptomatic or related organ

systemssystems– 2 – 7 body areas / organ systems2 – 7 body areas / organ systems

Detailed Detailed (214)(214)– ExtendedExtended exam of affected body area(s) and exam of affected body area(s) and other symptomatic or related organ systemsother symptomatic or related organ systems- - 2 – 7 body areas / organ systems2 – 7 body areas / organ systems

Comprehensive Comprehensive (215) (215)– CompleteComplete single system specialty exam or single system specialty exam or– CompleteComplete multi-system exam multi-system exam– 8 organ systems8 organ systems

Medical Decision MakingMedical Decision MakingDecision Making Decision Making 2 of 32 of 3

Number of Number of

DiagnosesDiagnoses

Amount of DataAmount of Data Risk of Risk of ComplicationComplication

Straight forwardStraight forward

(99212)(99212)

1 minor 1 minor problemproblem

Min. or NoneMin. or None ReassuranceReassurance

LowLow

(99213)(99213)

2 minor or 1 2 minor or 1 chronic illnesschronic illness

Hx from parentHx from parent OTC meds or 1 OTC meds or 1 chronic illnesschronic illness

ModerateModerate

(99214)(99214)

1 new problem 1 new problem or 2 established or 2 established w 1 worsening w 1 worsening

Hx from parent Hx from parent and 1 test and 1 test ordered or ordered or reviewedreviewed

Acute prob with Acute prob with systemic sxs or systemic sxs or Rx medRx med or mild or mild exacerbation of exacerbation of chronic illnesschronic illness

High ComplexityHigh Complexity

(99215)(99215)

1 new problem 1 new problem with W/U orwith W/U or

2 worsening2 worsening

Hx from parent Hx from parent and lab and and lab and other testother test

Severe Severe exacerbation of exacerbation of chronic illnesschronic illness

Medical Decision MakingMedical Decision Making

Best 2 of 3 elements: Data, Diagnoses, Risk Best 2 of 3 elements: Data, Diagnoses, Risk 1.1. Amount and/or complexity of Amount and/or complexity of datadata reviewed/ordered reviewed/ordered

– Note if you reviewed the chart or obtained history from Note if you reviewed the chart or obtained history from someone other than the patient, or discussed the case with someone other than the patient, or discussed the case with another healthcare provideranother healthcare provider

– Note if you intend to order old recordsNote if you intend to order old records– Note if you personally reviewed a specimen, image or tracing Note if you personally reviewed a specimen, image or tracing – Note any other diagnostic test results or orders Note any other diagnostic test results or orders

2.2. Number of Number of diagnosesdiagnoses and/or management options and/or management options – Note any workup plannedNote any workup planned– Note any comorbidities effecting decision making and status Note any comorbidities effecting decision making and status

of problems of problems

3.3. RiskRisk of complications, morbidity, mortality of complications, morbidity, mortality

Key Concepts – Outpatient E/M CodingKey Concepts – Outpatient E/M Coding

Time spent is Time spent is ““face to faceface to face”” One E/M code per dayOne E/M code per day

– Few exceptions:Few exceptions:» -25 modifier-25 modifier» Prolonged services codesProlonged services codes

Attending physician must see the patient and fulfill / Attending physician must see the patient and fulfill / document criteria supporting code useddocument criteria supporting code used

Procedures and other services should be coded separatelyProcedures and other services should be coded separately– May require modifiers (-25 on the E/M code)May require modifiers (-25 on the E/M code)

Office Visits – New PatientOffice Visits – New Patient

CodesCodes 9920199201 9920299202 9920399203 9920499204 9920599205

HistoryHistory Problem Problem FocusedFocused

Expanded Expanded Problem Problem FocusedFocused

DetailedDetailed Compre Compre

hensivehensive

Compre Compre

hensivehensive

ExamExam Problem Problem FocusedFocused


DetailedDetailed CompreCompre

hensivehensive

CompreCompre

hensivehensive

Decision Decision MakingMaking

Straight Straight forwardforward


Low Low complexcomplex

Moderate Moderate complexcomplex

High High complexcomplex

Time FFTime FF 1010 2020 3030 4545 6060

Key #Key # 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3

Office Visits – Established PatientOffice Visits – Established PatientCodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215

HistoryHistory Not Not RequiredRequired

Problem Problem FocusedFocused


DetailedDetailed Compre Compre hensivehensive

ExamExam Not Not RequiredRequired



Detailed Detailed Compre Compre hensivehensive


Not Not RequiredRequired


Low Low ComplexComplex

Mod Mod ComplexComplex

High High ComplexComplex

Time FFTime FF 55 1010 1515 2525 4040


TimeTime

An explicit factor to assist in selecting the most An explicit factor to assist in selecting the most appropriate level of E/M servicesappropriate level of E/M services

When counseling and/or coordination of care are When counseling and/or coordination of care are more than more than 50%50% of the face to face encounter, of the face to face encounter, then time is the key controlling factor.then time is the key controlling factor.

Utilize prolonged services codes (time based)Utilize prolonged services codes (time based)

**Documentation in the medical record is a mustDocumentation in the medical record is a must

Time Based CodingTime Based Coding

Established PatientEstablished Patient

9921199211 5 minutes5 minutes 9921299212 1010 9921399213 1515 9921499214 2525 9921599215 4040

New PatientNew Patient

9920199201 10 minutes10 minutes 9920299202 2020 9920399203 3030 9920499204 4545 9920599205 6060

The ART of CodingThe ART of Coding

The The ““FEELFEEL”” – Established Patient – Established Patient

– 99211 - Nurse Visit99211 - Nurse Visit

– 99212 - Easy, Brief Problems99212 - Easy, Brief Problems

– 99213 - Average, Usual Problems99213 - Average, Usual Problems

– 99214 - 99214 - ““ OH NO ! OH NO !””– 99215 - 99215 - ““ Just Ran a Marathon Just Ran a Marathon””

CodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215





Required Required Elements Elements

HPI 1-3 HPI 1-3 ROS N/A ROS N/A PFSH N/APFSH N/A

HPI 1-3 HPI 1-3 ROS 1 ROS 1 PFSH PFSH N/AN/A

HPI 4+ HPI 4+ ROS 2-9 ROS 2-9 PFSH 1/3PFSH 1/3

HPI 4+HPI 4+ROS 10+ROS 10+PFSH 2/3 PFSH 2/3





Required Required ElementsElements

1 Area 1 Area 2-4 Areas2-4 Areas 2-7 Areas2-7 Areas >8 Areas>8 Areas






High ComplexHigh Complex

Time FFTime FF 55 1010 1515 2525 4040


? 99213 ? 99213 99214 99214 99215 ? 99215 ? CSHCNCSHCN New DiagnosisNew Diagnosis Multiple DiagnosesMultiple Diagnoses Repeat visit – patient worseRepeat visit – patient worse ComorbiditiesComorbidities Lab or Xray ordered Lab or Xray ordered Consultation indicated Consultation indicated Prescription writtenPrescription written Office procedures required (aerosol, pulse ox)Office procedures required (aerosol, pulse ox) Chronic problem – exacerbation, changes in RxChronic problem – exacerbation, changes in Rx Time based problem/ Time based problem/ ““consultationconsultation””

Documentation/ ICD 9 CMDocumentation/ ICD 9 CM

ICD coding should support higher levels of coding ICD coding should support higher levels of coding ((medical necessitymedical necessity))

99213 to 9921499213 to 99214 Code multiple diagnosesCode multiple diagnoses Code comorbiditiesCode comorbidities Document chronic condition when an acute problem is Document chronic condition when an acute problem is

presentedpresented– Diabetes mellitusDiabetes mellitus– Prematurity and related problemsPrematurity and related problems– CSHCNCSHCN

??99213 – 99214 - 9921599213 – 99214 - 99215

You select the level !You select the level !

MAKE ME BETTER MAKE ME BETTER

A 12 yo teenager est patient presents with a sore A 12 yo teenager est patient presents with a sore throat for 2 days, associated with swollen glands. throat for 2 days, associated with swollen glands. An expanded problem focused Hx and PE are An expanded problem focused Hx and PE are done. A strep FA is obtained and treatment with done. A strep FA is obtained and treatment with acetaminophen/ibuprofen reviewed.acetaminophen/ibuprofen reviewed.

How would you code for this patient ?How would you code for this patient ?


A. 99212 A. 99212 87880 (strep FA)87880 (strep FA)

B. 99213 B. 99213 87880 (strep FA)87880 (strep FA)

C. 99214 C. 99214 87880 (strep FA)87880 (strep FA)

D. 99215 D. 99215 87880 (strep FA)87880 (strep FA)


A. 99212 A. 99212 87880 (strep FA)87880 (strep FA)

B. B. 99213 99213 87880 (strep FA)87880 (strep FA)

C. 99214 C. 99214 87880 (strep FA)87880 (strep FA)

D. 99215 D. 99215 87880 (strep FA)87880 (strep FA)

II’’M STILL SICK !M STILL SICK !

Our patient returns 5 days later. She is miserable, cannot Our patient returns 5 days later. She is miserable, cannot swallow, and looks dry. She is congested and has been swallow, and looks dry. She is congested and has been sleeping all the time. A detailed Hx and PE is completed. sleeping all the time. A detailed Hx and PE is completed. Lab work including a Mono spot, chem-8, and urinalysis Lab work including a Mono spot, chem-8, and urinalysis are ordered. Extensive discussion re the DDx, Rx and are ordered. Extensive discussion re the DDx, Rx and F/U is completed. The patient is treated with a short F/U is completed. The patient is treated with a short course of steroids when the Mono spot is positive.course of steroids when the Mono spot is positive.

How would you code for these services ? How would you code for these services ?


A. 99212 A. 99212 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

B. 99213 B. 99213 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

C. 99214 C. 99214 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

D. 99215 D. 99215 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))


A. 99212 A. 99212 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

B. 99213 B. 99213 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

C. C. 99214 99214 36415 (venipuncture) 36415 (venipuncture)

99000 (99000 (specimen specimen

transfertransfer))

D. 99215 D. 99215 36415 (venipuncture) 36415 (venipuncture) 99000 (99000 (specimen transferspecimen transfer))

QUICK SICKIE QUICK SICKIE

A 13yo boy comes in announcing he has poison A 13yo boy comes in announcing he has poison ivy. A brief Hx and PE support his diagnosis. It is ivy. A brief Hx and PE support his diagnosis. It is in several small patches on his extremities. in several small patches on his extremities. You treat with a topical steroid prescription.You treat with a topical steroid prescription.

How would you code for this quickie ?How would you code for this quickie ?

QUICKIE SICKIE QUICKIE SICKIE

A. 99211A. 99211

B 99212B 99212

C. 99213C. 99213

D. 99214D. 99214

DISASTER TIMEDISASTER TIME A 15 yo patient of your partner is scheduled with a cc of A 15 yo patient of your partner is scheduled with a cc of

““anxiety attacksanxiety attacks””. She is inappropriately scheduled in a 10 . She is inappropriately scheduled in a 10 minute ill appointment time. You complete a minute ill appointment time. You complete a comprehensive Hx, extended PE, and provide extensive comprehensive Hx, extended PE, and provide extensive counseling for this adolescent who is depressed and counseling for this adolescent who is depressed and suicidal. Total face to face time for this encounter is 50 suicidal. Total face to face time for this encounter is 50 minutes, with 30 minutes spent counseling and minutes, with 30 minutes spent counseling and coordinating care for this crisis.coordinating care for this crisis.

How would you code for this total loss of your lunch time ?How would you code for this total loss of your lunch time ?

DISASTER TIMEDISASTER TIME

A. 99213A. 99213

B. 99214B. 99214

C. 99215C. 99215

D. 99216 !D. 99216 !

FUSSY BABY FUSSY BABY

A 2 mos infant has been fussy since birth. He is A 2 mos infant has been fussy since birth. He is difficult to console and has been very spitting, difficult to console and has been very spitting, with vomiting once/ day. There have been no with vomiting once/ day. There have been no other symptoms of illness. A detailed history and other symptoms of illness. A detailed history and detailed examination are completed. 15 minutes detailed examination are completed. 15 minutes of face to face time are recorded for the visit.of face to face time are recorded for the visit.

How would you code for this fussy baby and How would you code for this fussy baby and fussy parent? fussy parent?

FUSSY BABY FUSSY BABY

A. 99212A. 99212

B. 99213B. 99213

C. 99214C. 99214

D. 99215D. 99215

FUSSY BABYFUSSY BABY

A. 99212A. 99212

B. 99213B. 99213

C. 99214C. 99214

D. 99215D. 99215

TEEN TROUBLE TEEN TROUBLE

A 13yo boy has been failing in school and was suspended A 13yo boy has been failing in school and was suspended today for threatening another student. Your assessment today for threatening another student. Your assessment includes a plan to evaluate for ADHD/ learning includes a plan to evaluate for ADHD/ learning disabilities, as well as, obtain counseling for his disabilities, as well as, obtain counseling for his significant home and school adjustment problems. Total significant home and school adjustment problems. Total face to face time for the visit is 45 minutes, with 30 face to face time for the visit is 45 minutes, with 30 minutes spent counseling and coordinating care related to minutes spent counseling and coordinating care related to the issues, Dx, and Rx options.the issues, Dx, and Rx options.

How would you code for this troubled teen visit?How would you code for this troubled teen visit?

TROUBLED TEEN TROUBLED TEEN

A. 99212A. 99212

B. 99213B. 99213

C. 99214C. 99214

D. 99215 D. 99215

Office Visits – Established PatientOffice Visits – Established PatientCodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215








Detailed Detailed Compre Compre hensivehensive






High High ComplexComplex

TimeTime FFFF 55 1010 1515 2525 4040Key #Key # 2 of 32 of 3 2 of 32 of 3 2 of 32 of 3 2 of 32 of 3 2 of 32 of 3

THE STANDARD ILL VISITTHE STANDARD ILL VISIT

A new patient 4 yo girl presents with several days A new patient 4 yo girl presents with several days of burning pain with urination. An expanded of burning pain with urination. An expanded problem focused history and expanded problem problem focused history and expanded problem focused examination are completed. A urinalysis focused examination are completed. A urinalysis with microscopic analysis is done. The diagnosis with microscopic analysis is done. The diagnosis is vulvitis and sitz baths are recommended.is vulvitis and sitz baths are recommended.

What would you code for this bread and butter What would you code for this bread and butter pediatric visit?pediatric visit?


A. 99202 A. 99202 81000 (u/a with micro)81000 (u/a with micro)

B. 99203 B. 99203 81000 (u/a with 81000 (u/a with

micro)micro)

C. 99204 C. 99204 81000 (u/a with micro)81000 (u/a with micro)

D. 99205 D. 99205 81000 (u/a with micro)81000 (u/a with micro)


A. A. 99202 99202 81000 (u/a with micro)81000 (u/a with micro)

B. 99203 B. 99203 81000 (u/a with 81000 (u/a with

micro)micro)

C. 99204 C. 99204 81000 (u/a with micro)81000 (u/a with micro)

D. 99205 D. 99205 81000 (u/a with micro)81000 (u/a with micro)

ANOTHER ONE!ANOTHER ONE!

A 3yo female presents with twelve hours of A 3yo female presents with twelve hours of fussiness and vomiting. She does not have fever fussiness and vomiting. She does not have fever and is urinating well. An expanded problem and is urinating well. An expanded problem focused history and examination are completed. focused history and examination are completed. Slowly advancing clear fluids is reviewed, as well Slowly advancing clear fluids is reviewed, as well as, when to call if her condition worsens.as, when to call if her condition worsens.

How would you code for this everyday patient?How would you code for this everyday patient?


A. 99212 A. 99212

B. 99213 B. 99213

C. 99214 C. 99214

D. 99215 D. 99215


A. 99212 A. 99212

B. 99213B. 99213

C. 99214 C. 99214

D. 99215 D. 99215

ANOTHER SICKER ONE!ANOTHER SICKER ONE!

A 5yo female presents with one day of vomiting. She has A 5yo female presents with one day of vomiting. She has a temp of 101, diarrhea, and lethargy. She is urinating a temp of 101, diarrhea, and lethargy. She is urinating less and not tolerating less and not tolerating ““anythinganything””. A detailed history and . A detailed history and examination are completed. A negative urinalysis is examination are completed. A negative urinalysis is obtained with a specific gravity of 1.020. Management is obtained with a specific gravity of 1.020. Management is reviewed: slowly advancing clear fluids, treatment of reviewed: slowly advancing clear fluids, treatment of fever, and when to call.fever, and when to call.

How would you code for this everyday patient?How would you code for this everyday patient?

ANOTHER SICKER ONE!ANOTHER SICKER ONE!

A. 99212 A. 99212 81002 (dip urinalysis)81002 (dip urinalysis)

B. 99213 B. 99213 8100281002

C. 99214 C. 99214 8100281002

D. 99215 D. 99215 8100281002

Preventive Medicine ServicesPreventive Medicine Services

New PatientNew PatientInitial E/M of a new patient including Initial E/M of a new patient including an age and gender an age and gender appropriate history, examinationappropriate history, examination

identification of risk factors, ordering of appropriate identification of risk factors, ordering of appropriate tests, and counseling tests, and counseling $ 2014 Medicare$ 2014 Medicare

99381 99381 Age < 1 year Age < 1 year $111.05 $111.0599382 99382 Ages 1 – 4 years Ages 1 – 4 years $115.71 $115.719938399383 Ages 5 – 11 years Ages 5 – 11 years $115.67 $115.6799384 99384 Ages 12 – 17 years Ages 12 – 17 years $131.25 $131.2599385 99385 Ages 18 – 39 years Ages 18 – 39 years $127.26 $127.26

Preventive Medicine ServicesPreventive Medicine Services

Established PatientEstablished PatientPeriodic reevaluation and management requiring Periodic reevaluation and management requiring an age an age and gender appropriate history, examination and gender appropriate history, examination identification of risk factors, ordering of studies, and identification of risk factors, ordering of studies, and counseling counseling 2014 Medicare 2014 Medicare

9939199391 Age < 1 Age < 1 $99.95 $99.959939299392 Ages 1 – 4 years Ages 1 – 4 years $106.75 $106.759939399393 Ages 5 – 11 years Ages 5 – 11 years $106.39 $106.399939499394 Ages 12 – 17 years Ages 12 – 17 years $116.42 $116.4299395 99395 Ages 18 – 39 years Ages 18 – 39 years $118.93 $118.93

Preventive Medicine vs Preventive Medicine vs E/M Office Visit ?E/M Office Visit ?

What do you do if a What do you do if a significantsignificant illness or problem is illness or problem is found at a preventive medicine visit?found at a preventive medicine visit?

25 Modifier25 Modifier

If a If a significantsignificant problem/abnormality is found at problem/abnormality is found at a preventive medicine visit:a preventive medicine visit:– Code the appropriate E/M visit in addition to Code the appropriate E/M visit in addition to 99381 – 9939599381 – 99395- Add modifier Add modifier –25–25 to the E/M code to the E/M code- If not significant code only 99381 – 99395If not significant code only 99381 – 99395

- Option: Have patient return for a separate E/M Option: Have patient return for a separate E/M visit for problem/abnormality foundvisit for problem/abnormality found

PM + E/M-25 ModifierPM + E/M-25 Modifier

SignificantSignificant Problem: Problem:– Separate DocumentationSeparate Documentation– Separate Supporting DiagnosisSeparate Supporting Diagnosis– Prescription or Lab/ Xray Testing orderedPrescription or Lab/ Xray Testing ordered– Consultation RequiredConsultation Required– Time intensive ProblemTime intensive Problem

AcuteAcute Chronic requiring discussion and/or interventionChronic requiring discussion and/or intervention

PM + E/M-25 ModifierPM + E/M-25 Modifier

Preventive MedicinePreventive Medicine– No copayNo copay– Not applied to deductibleNot applied to deductible

++ EM – 25 EM – 25– CopayCopay– Subject to deductibleSubject to deductible

Educate your patients and familiesEducate your patients and families

?? WELL BABY TIME WELL BABY TIME A 6 month infant boy presents for an est preventive visit. A 6 month infant boy presents for an est preventive visit.

His mother is worried about the cold and fever he has His mother is worried about the cold and fever he has had for several days. An age and gender appropriate Hx had for several days. An age and gender appropriate Hx and PE are completed, in addition to an extended Hx and PE are completed, in addition to an extended Hx addressing the ongoing illness. A Dx of otitis media is addressing the ongoing illness. A Dx of otitis media is made and the infant is treated with po amoxicillin. His made and the infant is treated with po amoxicillin. His mother is not comfortable with proceeding with mother is not comfortable with proceeding with immunizations. It is agreed that she will return in several immunizations. It is agreed that she will return in several weeks for a nurse only visit to obtain these important weeks for a nurse only visit to obtain these important vaccines.vaccines.

How would you code for this office visit ?How would you code for this office visit ?

? WELL BABY TIME? WELL BABY TIME

A. 99391A. 99391

B. 99214B. 99214

C. 99391 C. 99391 99212-2599212-25

D. 99391 D. 99391 99213-2599213-25

? WELL BABY TIME? WELL BABY TIME

A. 99391A. 99391

B. 99214B. 99214

C. C. 99391 99391 99212-2599212-25

D.D. 99391 99391 99213-2599213-25

Office proceduresOffice procedures

ImmunizationsImmunizations Screening proceduresScreening procedures Minor proceduresMinor procedures Lab and x-ray servicesLab and x-ray services Medical servicesMedical services Special servicesSpecial services

Immunizations 2014Immunizations 2014

How are you doing ?How are you doing ?

What are your challenges?What are your challenges?

ImmunizationsImmunizations Bill and Document Bill and Document ALLALL::

– E/M Visit - E/M Visit - 2525 » Office Visit, Preventive MedicineOffice Visit, Preventive Medicine

– Immunization AdministrationImmunization Administration» 90471 – 9047490471 – 90474 (individual vaccine based)(individual vaccine based)» 90460 – 90461 (component based) 90460 – 90461 (component based)

– Vaccine/ToxoidVaccine/Toxoid» 90476 – 9074990476 – 90749

Link to ICD DiagnosesLink to ICD Diagnoses– V20.2 Well ChildV20.2 Well Child– CSHCN DiagnosisCSHCN Diagnosis– + Specific Vaccine V Codes (+ Specific Vaccine V Codes (Z23Z23 ICD-10) ICD-10)

Office proceduresOffice procedures

ImmunizationsImmunizations Screening proceduresScreening procedures Minor proceduresMinor procedures Lab and x-ray servicesLab and x-ray services Medical servicesMedical services Special servicesSpecial services

Screening servicesScreening services

2014 Medicare 2014 Medicare 92583 - hearing screen, select picture92583 - hearing screen, select picture $51.94 $51.94 92551 - hearing screen, pure tone92551 - hearing screen, pure tone $11.82 $11.82 92552 –hearing screen, pure tone threshold 92552 –hearing screen, pure tone threshold $30.81 $30.81 99173 - visual acuity screening99173 - visual acuity screening $ 2.87 $ 2.87

– may be reported w/ preventive care codes, may be reported w/ preventive care codes, not if part of an E/M service of the eyenot if part of an E/M service of the eye

Developmental Screening CodeDevelopmental Screening CodeCentral Nervous System Assessments/TestsCentral Nervous System Assessments/Tests

9611096110 Developmental ScreeningDevelopmental Screening Performed by office nurse or other trained non-physician Performed by office nurse or other trained non-physician

personnelpersonnel Parent/guardian report of behaviorParent/guardian report of behavior $8.24$8.24 2014 Medicare 2014 Medicare Modifier 25 may be attached to associated E/M visitModifier 25 may be attached to associated E/M visit Modifier 59 to multiple additional testsModifier 59 to multiple additional tests Interpretation and report Interpretation and report

Documentation in progress report of E/M visitDocumentation in progress report of E/M visit

96110 Examples96110 Examples

Ages and Stages Questionnaire (ASQ)Ages and Stages Questionnaire (ASQ) Brigance Early Preschool Brigance Early Preschool Developmental Profile IIDevelopmental Profile II Early Language Milestone ScalesEarly Language Milestone Scales PEDSPEDS PDQPDQ VanderbiltVanderbilt MCHATMCHAT

NOT direct physician observation or NOT direct physician observation or general general developmental assessment with developmental assessment with checklist of milestones checklist of milestones appropriate for ageappropriate for age

Depression ScreeningDepression Screening

96110 Adolescent depression screening96110 Adolescent depression screening

($8.24 - ($8.24 - 2014 Medicare2014 Medicare))

99420 Maternal depression screening 99420 Maternal depression screening ($10.75 - ($10.75 - 2014 Medicare2014 Medicare))

20152015CNS Assessments / TestsCNS Assessments / Tests

96110 – Developmental screening with scoring 96110 – Developmental screening with scoring and documentation, per standardized formand documentation, per standardized form

9612796127 – Brief emotional/behavioral assessment – Brief emotional/behavioral assessment (depression inventory, ADHD scale, with scoring (depression inventory, ADHD scale, with scoring and documentation, per standardized instrumentand documentation, per standardized instrument

Preventive Medicine Ancillary ServicesPreventive Medicine Ancillary ServicesScreening 2014 Medicare

Hearing testing - Select picture 92583 $51.94Hearing testing – Puretone 92551 $11.82Hearing testing – Puretone(threshold) 92552 $30.81Vision screening 99173 $2.87Developmental Screening 96110 $8.24

LabHemoglobin 85018 $3.26Urine (dip only) 81002 $3.24Routine Venipuncture 36415 $3.00Finger/Heel Stick 36416 $4.95

ImmunizationsImmunization administration 90471/90460 $25.08/$25.08

90472/90461 $12.54$/12.54Vaccine/Toxoid product 90476-90479

OtherInjection/other 96372 .76/ $25.08

DOCUMENT !DOCUMENT !



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Coding publications: Coding for Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-10-CM Quick Reference Guides, ICD-10-CM Resources, RBRVS Brochure, Resources, RBRVS Brochure, AAP NewsAAP News Coding CornerCoding Corner

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