USAFP BusinessCoding Workshop, March 2006

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USAFP Business-Coding Workshop, March 2006

• DALE R. AGNER, Lt Col, USAF, MC, SFS
• Commander, 42d Medical Operations Squadron
• Maxwell AFB, AL 36112
• dale.agner_at_maxwell.af.mil
• Telephone [phone]

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Overview

• Procedures
• Consults
• Principles of EM, CPT
• Office procedures counting for RVUs
• E.g.Colpos/vasectomy
• Preventive Visits
• Well Appts
• IMR/Readiness
• Immunizations

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Top 10 Errors

• Presumptive Coding
• Using E/M for global follow-up visit
• Need diagnostic E-code for initial tx of injury
• Pregnancy incidental (for correct dx)
• PHAs and other administrative encounters
• Code annual GYNs with 9938x/9939x
• Pap collection is Q0091
• Injected drugs, not issued to pt by pharmacy
  (usually J-codes, some C-codes, some S-codes)
• One up or one down in the E/M. Most provider
  99211s could be 99212s based on documentation.
• Missing CPTs

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Consults to FP, from FP

• Scope of practice not uniformly in clinic (MEPR)
• Osteopathic manipulation
• Colposcopy/vasectomy/endoscopy
• Some derm
• (e.g. accutane, more complicated office
  procedures)
• Not your own patient
• Need Request, Reason, Report
• Must document
• What and why on the consult
• Report provided/sent/communicated to originator

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Procedures - Medical Necessity

• A service that is reasonable and necessary for
  the diagnosis or treatment of illness or injury,
  or to improve the functioning of a malformed body
  member
• consistent w/symptoms or dx of the illness or
  injury under treatment
• consistent w/generally accepted professional
  medical standards
• not furnished primarily for the convenience of
  the patient, the attending physician, or another
  physician or supplier and
• furnished at the most appropriate level, which
  can be provided safely and effectively to the pt

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Procedures - General

• Office visit codes should not be billed the same
  day as a procedure is performed unless
• it is the first evaluation for that issue/done
  day identified
• a completely separate problem
• a change in plan
• Otherwise, when there is no applicable Evaluation
  and Management (EM) code - use holding office
  visit code of 99499 for the day of the visit

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Procedures - General

• For follow-up visits, if the dx no longer exists
  (e.g., laceration, neoplasm, cyst) code only
  V-code for the follow-up visit or suture
  removal/dressing change
• Pain Management - is an office visit
• But nerve blocks done during pain management
  visits are codable

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Procedures - Anesthesia - Conscious Sedation

• Can only be used by surgeon doing procedures
• Includes monitoring of cardiorespiratory function
  (e.g., pulse ox, cardiorespiratory monitor, and
  BP)
• Must have independent trained observer to assist
  provider in monitoring patient
• 99141 Sedation, w or w/o analgesia IV, IM,
  inhalation
• 99142 Sedation, w or w/o analgesia oral, rectal
  and /or intranasal

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Procedures - Surgical

• Colonoscopy
• Drain abscess
• Drain blood from under nail
• Infant circumcision
• Remove cerumen
• Remove foreign bodies (ear, nose, eye,
  esophagus)
• Remove nail
• Remove warts
• Strapping/splinting
• Treatment of fracture (the casting material is
  HCPCS code)
• Removal of cast is put on by someone other than
  in your MTF

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Procedures - Lab/Rad/Diagnostic Imaging 7xxxx(DI)
8xxxx(Lab)

• Code if done and interpreted in the clinic e.g.,
  most labs and diagnostic imaging not coded
• Common exceptions, CLIA waived tests in the
  table Diagnostic Ultrasound of Pelvis
  76805-76857 in OB clinic

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Procedures - Medicine90000-99199

• If using code from this section without an EM,
  use the 99499 holding code (this work around
  will go away when ADM is changed to accept
  procedures without an EM)
• Immunizations
• Psychiatry (make sure time is annotated)
• Ophthalmology/Optometry
• EKG/treadmill
• Allergy (each skin test is a unit)
• PT/OT (make sure time is annotated)
• Osteopathic manipulations/acupuncture/chiropractic
  
• Audiology

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Procedures - Medicine90000-99199

• Immunizations (see notes below)
• Injections - 90782/90784/90788
• Use a J-code, S-code or C-code if there is one,
  for the injectable unless the injectable came
  from the pharmacy
• Psych Drug Mngt - 90862 - (ADHD) only use if no
  E/M, if in conjunction with E/M then it becomes
  part of the history/exam/decision
• Vision Screening 99172/3 no RVUs, just if you
  need it for your records

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Procedures - Medicine

• EKGs 93010/Treadmills 93015
• If read by physician who orders entered by that
  physician (if inpt, put in A MEPRS if outpt,
  put in B MEPRS)
• If ordered by one service, read by internist at
  administering facility entered by internist in
  D MEPRS account
• If read by internist at separate reading facility
  entered in F MEPRS account
• Only one person may take credit for tracing, only
  one may take credit for the reading/interpretation
  
• Spirometry 94010
• Nebulizer 94640
• After hours services 99050/2/4/6/8

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Procedures MedicineBe careful

• 36400/36410/36415 Venipunctures only use if
  this is only thing done, usually part of the
  visit
• 92002/4 Ophthalmologic services is NOT vision
  screening (99172/3)
• 92283 Color Vision exam, extended (e.g.,
  anomaloscope)
• Pseudiosochromatic plates - such as Ishihara not
  reported separately
• 93740 Temperature Gradient (not temp)
• 93784-93790 Blood Pressure - 24 hour - (this is
  not the B/P when a pt walks in)
• 97116 Gait Training (not crutches education)

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Procedures - Medicine

• Supplies and materials over and above
• 99070
• Educational materials - if the military health
  system incurs a cost (not drug rep stuff) 99071
• Physician group education svs 99078
• Use EM of 99499
• Dopplers simple hand-held or other Doppler
  devices that dont produce a hard copy output or
  does not permit analysis of bidirectional
  vascular flow this is part of the exam, not a
  separately codable procedure

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No Code For This

• Otoscopy no code for this
• Rhinoscopy no code for this
• Whispered voice test no code for this
• Tuning fork tests no code for this
• Throat culture no code for this

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Procedures - Surgical

• Multiple procedures - Code the most expensive
  first, then code others.
• -51 modifier for multiple procedures

CPT
Mod
Nomenclature
Work RVU
45378
Diagnostic colonoscopy
3.69
45378
53
Diagnostic colonoscopy
0.96
45379
Colonoscopy w/fb removal
4.68
45380
Colonoscopy and biopsy
4.43
45381
Colonoscopy, submucous inj
4.19
45382
Colonoscopy/control bleeding
5.68
45383
Lesion removal colonoscopy
5.86
45384
Lesion remove colonoscopy
4.69
45385
Lesion removal colonoscopy
5.30
45386
Colonoscopy dilate stricture
4.57
45387
Colonoscopy w/stent
5.90
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MISCELLANEOUS
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CARDIO-PULMONARY
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Ear Nose and Throat
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GU-Reproductive
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Musculo-skeletal
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Dermatology
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Dermatology-continued
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Top 10 Errors

• Presumptive Coding
• Using E/M for global follow-up visit
• Need diagnostic E-code for initial tx of injury
• Pregnancy incidental (for correct dx)
• PHAs and other administrative encounters
• Code annual GYNs with 9938x/9939x
• Pap collection is Q0091
• Injected drugs, not issued to pt by pharmacy
  (usually J-codes, some C-codes, some S-codes)
• One up or one down in the E/M. Most provider
  99211s could be 99212s based on documentation.
• Missing CPTs

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Prevention Coding

• Preventive Medicine Services 99381-99412
• Initial Preventive Medicine (physicals), based on
  age 99381-7
• Periodic Preventive Medicine (physicals), based
  on age 99391-7
• Individual Counseling 99401-4
• PHAs without a significant physical by a provider
  
• Group Counseling 99411-2
• Work Related or Medical Disability Exam
  99455-99456 (Return to Duty)

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PHA

• 99401/2 if Pt is seen (15/30 minutes of
  counseling)
• Primarily counseling is given and documentedE.g
  GERD that is diagnosed/treated durin the PHA
• 9939X may be used, but would require a full
  wellness exam
• 99499-if Pt not seen
• May include
• EKG
• PFT
• Audiogram
• with 99499
• Tech can enter
• Oh by the way
• Specific complaints can be coded
• receive a modifier and 99212/3/4 as appropriate

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Group Appointments

• May Count for RVUs if
• Individual provider interaction with Pt. occurs
• Documented SOAP format
• PHA
• Group education (provider)
• Need individual assessment
• If provider does not see, may still obtain a CPT
  in a 99499 appt. (EKG, Audiogramwith
  interpretation/report, may hand-write in record
  or on report)

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Counseling vs Education

• Counseling/Prevention/Risk Factor Reduction -
  before there are symptoms, a condition or
  established illness - counts as a separate
  prevention visit, does not need history, exam, or
  decision making
• Education - after there are symptoms, a condition
  or established illness

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CPT, Work-RVU, Tot-Fac-Impl

• 92567 Tympanometry 0.52 1.04
• 93000 EKG complete 0.17 0.71
• 94010 Breath-capacity test 0.17 0.87
• 94016 Review pt spirometry 0.52 0.71
• 94375 Resp flow vol loop 0.31 0.94
• 98925 Osteopath manip 0.45 0.61
• 98926 Osteopath maniplt 0.65 0.93
• 99172 VisFunc Scrn-color 0.21 0.66
• 99173 VIS ScreeningTEST 0.11 0.33

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Privileged or Non-Privileged

• Privileged providers
• May use all E/M codes
• Use 99499 if no E/M for the encounter
• Non-privileged providers
• Use 99211 if encounter w/o procedure
• Use 99499 if encounter w/procedure
• Use For Clinic Use Only to collect types and
  times

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MEB, Overseas Clearance

• Physician case management is a process in which a
  physician is responsible for direct care of a
  patient, and for coordinating and controlling
  access to or initiating and/or supervising other
  health care services needed by the patient.
  (Patient not present)
• Based on time documented
• 99361 for approximately 30 minutes
• 99362 for approximately 60 minutes
• Or.99212 for appropriate elements (overseas)
• 99214 or 99215, if dictated day of seeing patient
• Other option is the 25 modifier for time
  services

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Injections

• Immunization administration
• 90471 0.17 wRVU (one vaccine)
• 90472 0.15 wRVU (each addl)
• Provider has seen pt. and ordered immun.
• Tech must be in same MEPR as provider
• Tech must have administered in same location
• E.g. IBT 4Ns giving vaccines in Peds clinics
• Need to include the specific vaccine
• No specific RVU credit for just documenting the
  vaccine, need also the immunization
  administration piece

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DEPLOYMENT LINE RVUs

• Ensure one captures any immunizations
• Associate with the providers B clinic
• Provider must be on mobility line
• and document in medical record
• 99499 appointment, signed by physician
• (if not seen by provider, but present and
  supervising)
• Not a 99211
• (although captured in Medicare, we are DoD)
• If one puts in as tech time
• No RVUs captured
• Also - pre/post deployment physicals
• In the B clinic, RVUs associated, if saw Pt.

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DEPLOYMENT

• Processing patients on the line
• GBBA
• In the clinicpre/post deployment physicals
• In the B clinic, RVUs associated, if saw
  patient
• Ensure one captures any immunizations
• Associate with the providers B clinic
• 99499 appointment, signed by physician
• If one puts in as tech time
• No RVUs captured

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Questions?

• I Love to Code!
• (Flea I be. I be Flea.)
• That Flea-I-be, that Flea-I-be!
• I do not like that Flea-I-be.
• Would you like to code with me?
• I would not like to code with ye!
•  
• Would you code charts for your boss?
• Would you code at any cost?
• I would not code charts for my boss, I would not
  code at any cost!
• I will not code my charts today please
  Flea-I-be, please go away!
•  
• Would you code for CPGs?
• Would you code for TPCs?
• Would you code for Uncle Sam?
• (That anthrax genies on the lam!)
• I will not code for CPGs, I will not code for
  TPCs.
• Public health is not much fun, the only n I
  know is one!
• I will not code charts for my boss, I will not
  code at any cost.

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EM Modifiers

• 21 Prolonged EM Svs
• 24 Unrelated EM by same provider during post op
  period
• 25 Significant, separately identifiable EM by
  same provider on same day of procedure or other
  service
• Use if you do an office visit and that causes you
  to identify a need to do a global 0 or 10 day
  procedure that same day (e.g., remove ingrown
  nail, remove skin tags)
• 32 Mandated service (e.g., required by
  insurance)
• 57 Decision for surgery
• Use if you do an office visit that causes you to
  identify and do a global 90 day procedure
  within 24 hours (e.g., fx, ectopic pregnancy)

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EM Quantity

• Usually only used with
• 99355 Prolonged physician service in the office
  or other outpatient setting requiring direct
  (face-to-face) patient contact beyond the usual
  service each additional 30 minutes
• 99292 Critical care each additional 30 minutes
• Some others, very uncommon
• 99290 Critical care transport of child less than
  24 months, each additional 30 min