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Coding for Local Health Department Satellite School Sites

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Title: Coding for Local Health Department Satellite School Sites


1
Coding for Local Health Department Satellite
School Sites
Presented by Cynthia Robinson, IPA II
  • Kentucky Department for Public Health Division of
    Administration and Financial Management
  • Local Health Operations Branch
  • July, 2010

2
Table of Contents
  • Coding on the PEF
  • Determination of New or Established Patients
  • Coding of Preventive Visits
  • Components for coding Other than Preventive E/M
    Visits
  • Coding of Problem Visits New Patients
  • Coding of Problem Visits Established Patients
  • Multiple Visits for the Same Patient on the Same
    Day
  • Miscellaneous

3
  • This presentation was done to aid employees of
    local health department satellite school sites in
    coding and reporting of services. It could not
    possibly cover all of the circumstances which
    occur in these satellite sites on a day to day
    basis. This presentation is intended to assist in
    the training of new employees and retraining of
    existing ones.

4
Internal Review Process
  • DPH recommends each local health department
    have their own policy for reviewing their coding
    and medical records.

5
Guiding Principles
  • Only provide the level of care that is medically
    necessary per clinical judgment.
  • Always provide and document services in
    accordance with the Public Health Practice
    Reference and with established best practices.
  • Always code and document exactly what care was
    provided.

6
Coding on the PEF
7
Coding on the PEF
  • The state-maintained CH-45 (PEF) is recommended
    to use in health department clinics. (Shown on
    next slide.)
  • Many of the codes on the PEF are not used at
    satellite sites, some health departments prefer
    to create and use an abbreviated PEF at these
    sites. This is entirely permissible.
  • Local Health Departments using their own forms
    are responsible for keeping these forms updated.

8
(No Transcript)
9
Codes
  • Current Procedural Terminology (CPT) A set of
    codes, descriptions, and guidelines intended to
    describe procedures and services performed by
    physicians and other health care providers.
  • CPT codes describe WHAT was done for the patient.
  • International Classification of Disease 9th
    Revision 2009 (ICD-9) This system is required
    for reporting diagnoses and diseases to all U.S.
    Public Health Service and Department of Health
    and Human Services Programs, such as Medicare and
    Medicaid.
  • ICD-9 codes describe WHY it was done.

10
Examples of Codes
CPT codes - WHAT
ICD-9 codes - WHY
  • 99211 Office or other outpatient visit for the
    evaluation and management of an established
    patient that may or may not require the presence
    of a physician.
  • 99173 Screening test of visual acuity,
    quantitative, bilateral.
  • 36416 Collection of venous blood by capillary
    stick.
  • 99707 Measles, mumps, and rubella (MMR)
    vaccine, live, for subcutaneous use.
  • 99471 Immunization administration (includes ID,
    SQ, or IM injections) one single or combination
    vaccine/toxoid.
  • V202 Routine infant or child health check.
  • V069 Need for prophylactic vaccination and
    inoculation against combinations of diseases.
  • V741 Pulmonary tuberculosis, special screening
    for
  • 7840 Headache, pain in head
  • 7847 Epistaxis, nosebleed

11
Coding on the PEF
  • Coding in local health department satellite
    school sites consists of
  • Preventive Visits (e.g. well child exam)
  • Evaluation/Management visits, which LHDs
    commonly refer to as problem visits (e.g.
    headache, routine vaccines, sore throat)

12
Coding on the PEF
  • Preventive Visits (e.g. Well Child Exams)
  • Top left corner of PEF
  • 99381-99397 for Physicians/mid-level providers
  • W9381-W9397 for Nurses

13
Coding on the PEF
  • Other E/M Visits (Problem Visits)
  • Top right corner of PEF
  • 99201-99215 for Physicians/mid-level providers
  • W9201-W9215 for Nurses

14
Coding on the PEF Provider Level
  • REMEMBER
  • 992 codes - for use by physicians and mid level
    providers only
  • W92 codes - for use by nurses (RN or LPN)
  • LPNs may not code a higher level of visit than a
    W9202 - Expanded for a new patient or a W9213 -
    Expanded for an established patient.
  • Physicians and mid level providers code in the
    upper portion of the Preventive and Other Than
    Preventive Sections (RED).
  • Nurses code in the lower portion of the
    Preventive and Other Than Preventive Sections
    (YELLOW).

15
Coding on the PEF- CPT codes
  • CPT codes for immunizations, injection codes,
    etc. that are done as part of the visit must
    be....
  • Checked in the appropriate
    box on the PEF
  • OR, if the service is not listed on the PEF it
    must be written in the area provided

16
Coding on the PEF - ICD codes
  • ICD codes need to be written on the PEF in the
    section that corresponds with the office visit
    that was checked.
  • ICD codes will reflect why the patient presented.
    They are assigned based on the presenting
    problem(s) of the patient.
  • REMEMBER ICD codes for LHDs must be five digits.
    If the code is 3 or 4 digits, add dashes to make
    the code 5 digits long.

17
Coding on the PEF - ICD codes
  • There is a box for a primary (P) ICD and a
    secondary (S) if needed.
  • For example...a 4 y/o established patient,
    receives well child exam by a nurse (V202-) and
    also receives vaccines (V069-).
  • This would be coded on the preventive side of the
    PEF

V202-
v
V069-
18
Coding on the PEF - ICD codes
  • There is a box for a primary (P) ICD and a
    secondary (S) if needed.
  • Established patient presents to nurse for
    headache and sore throat
  • This is a problem visit and is coded on the E/M
    side of the PEF

7840-
462--
v
19
ICD Codes In Local Health Department Satellite
School Sites
  • ICD codes are revised annually and are effective
    on October 1 of each year.
  • Many LHDs create their own listing of most
    commonly used ICD codes.
  • REMEMBER These lists must be updated annually.

20
Determination of New or Established Patients
21
New Established Patients
  • The Patient Encounter Form (PEF or CH-45)
    distinguishes between New Patients and
    Established Patients
  • New Patients visits are coded in the areas
    highlighted in PINK.
  • Established Patients visits are coded in the
    areas highlighted in BLUE.

22
New Established Patients
  • NEW PATIENT - a patient who has not been seen at
    any health department or satellite clinic in the
    COUNTY within the past three years.
  • Determination of new or established status is
    made on a COUNTY basis, not a district basis.

23
New Established Patients
  • The PSRS (Patient Services Reporting System)
    determines whether the patient is new or
    established at computer registration when the PEF
    label is created.
  • The computerized registration process is
    generally not done at the satellite school site
    itself, often making it difficult for the
    provider to know whether the patient is new or
    established.

24
New Established Patients
  • If the provider cannot determine whether the
    patient is new or established by looking at the
    medical record, the provider should check the
    appropriate new patient level of visit and the
    appropriate established patient level of visit on
    the PEF. (See example on next slide.)
  • This will save time for the provider and for
    staff doing the data entry. The PEF will not need
    to be sent back to the nurse for determination of
    level of visit.

25
New Established Patients
  • Patient presents to nurse with headache...
  • Staff doing data entry should look at label to
    determine if it is a new patient or established,
    then...
  • Enter correct office visit
  • Mark through other visit

7840-
v
v
26
New Established Patients
  • Under NO circumstances should staff entering data
    change the level of visit to accommodate a new or
    established patient (unless that level was also
    marked on the PEF, as discussed in the previous
    slide).
  • The provider must determine the level of visit.

27
New Established Patients
  • A copy of the patients registration and consent
    form should be attached to the PEF if the
    provider believes that the patient is new.
  • This will expedite the registration process and
    enable services to be entered in a more timely
    manner.
  • If chart labels are needed, these should be
    requested at this time also.

28
New Established Patients
  • REMEMBER Chart labels from the PSRS are the
    easiest way to meet the criteria for patient
    name, patient number and clinic identifier to be
    present on all medical records forms.
  • This rule does not apply to preprinted visit
    forms. Only standard forms, such as the service
    note and the CH-12 are required to have this
    information.

29
Coding of Preventive Visits
30
Coding of Preventive Visits
  • Preventive visits are reported when the patient
    receives a full preventive physical exam per the
    guidelines in the Public Health Practice
    Reference (PHPR).
  • Coding of these visits require three components
  • New or established patient status
  • Age of patient
  • Completion of physical exam by protocols which
    are listed in the PHPR

31
Coding of Preventive Visits
  • If you are unable to complete some part of the
    required physical exam which has a stand alone
    CPT code (immunizations, urine dipstick, vision,
    hearing, etc.), you will not need to code a
    reduced service modifier 52.
  • Efforts must be made to complete these services
    as soon as possible. These are requirements for
    preventive services which are addressed in the
    PHPR.

32
Coding of Preventive Visits
  • REMEMBER If you are not able to complete some
    requirement of the physical, other than stand
    alone CPT codes (immunizations, urine dipstick,
    vision, hearing, etc.), you will need to report
    the 52 Reduced Service Modifier.
  • In order to receive 100 reimbursement, the
    remaining part of the exam must be completed
    within 30 days.
  • When the patient returns to finish the physical
    you will code the same preventive visit code and
    report the 52 modifier again.

The 52 modifier is located beneath the preventive
codes section. You may either check the box or
circle the 52.
33
Coding of Preventive Visits
  • If the patient is returning for completion of a
    stand alone CPT portion of the physical within
    the thirty day time period code...
  • 80000 code instead of an office visit (found in
    lower left corner of PEF see example below)
  • V202- (preventive visit pediatric patient ICD
    code)
  • Mark the appropriate CPT code for the procedure
    or service being performed (urine dip, hearing
    test, etc.)
  • This will prevent billing Medicaid for two office
    visits within the thirty day billing span.


V202-
v
34
Coding of Preventive Visits
  • If the patient returns after thirty days for the
    completion of the stand alone CPT portion of the
    preventive physical, it is permissible to code an
    Other E/M Office Visit (problem visit) for this
    service along with the CPT code for the procedure.

35
Components for coding Other than Preventive E/M
Visits
  • Commonly Referred to as Problem Visits in
    Health Department Settings

36
Components of Problem Visits
  • Problem Visits are made up of three components
    which are directly linked to the coding of these
    services.
  • History-consists of a combination of three parts
  • History of present illness
  • Review of systems
  • Past, family and social history
  • Exam
  • Decision making
  • These three components are the driving forces
    behind the coding of Problem Visits.
  • Understanding these three components is extremely
    important in accurate coding of problem visits.

37
History
  • Subjective documentation that is reported by
    the patient.
  • Comparable to the S (subjective) portion of the
    SOAP note
  • Combination of three components
  • History of present illness what the patient
    reports as problems, symptoms, time frames, etc.
  • Review of systems what body systems are
    affected by the presenting problems
  • Past, family and social history what past,
    familial or social influences there might be on
    the seriousness and resolution of the problem

38
Exam
  • Objective what the provider notes when
    assessing the patient
  • The exam is comparable to the O (objective)
    portion of the SOAP note
  • The exam portion will be discussed in detail in
    the Coding of Problem Visits - New Patients
    section of this presentation

39
Decision Making
  • The decision making component consists of three
    parts...
  • Presenting problem management options
  • Comparable to the A (assessment) portion of a
    SOAP note.
  • After looking at the patient history and
    performing exam as needed, the assessment of what
    the patients problem(s) are

40
Decision Making
  • Diagnostic procedures ordered
  • Provider must decide what, if any, diagnostic
    procedures should be done
  • Management options selected
  • What treatment the patient should receive
  • The last two parts combined are comparable to the
    P (plan) portion of a SOAP note

41
Coding of Problem Visits
  • New Patients

42
Coding of Problem Visits New Patients
  • American Medical Association (AMA) rules require
    that you have documented some of each of these
    components for new patients
  • History
  • Exam
  • Decision making
  • The AMA rules state that you must code Other E/M
    Office Visits for new patients to the lowest of
    these three components. By lowest of these three
    components, they mean the component which has the
    least impact on the visit.
  • Should you be missing one of the three components
    on a new patient, an 80000 code will have to be
    used.
  • This code gives you no reimbursement and no Work
    Resource Based Relative Values. So the time spent
    with this patient will be as though it never
    happened.

43
Coding of Problem Visits New Patients
  • The exam component will be the lowest of the
    three components 99 of the time.
  • New patients will be coded by the amount of exam
    performed (which are commonly referred to as
    exam bullets because this is how they are
    identified in CPT classification).

44
Exam New Patients
  • The five most common bullets are
  • General Appearance/Nutritional Status. (Although
    these appear on two lines of the HP/CH-13 and
    HP/CH-14 exam forms, they only count as one
    bullet.)
  • Mood and Affect
  • Orientation
  • Skin (2 bullets possible)
  • Inspection looking (e.g. pink, tan, intact)
  • Palpation - touching (e.g. warm, dry)
  • Vital signs can be used as an exam bullet also,
    but three vital signs from the following list
    MUST be done for it to count as a bullet
  • Sitting or standing blood pressure
  • Supine blood pressure
  • Height
  • Weight
  • Temperature
  • Pulse
  • Respiration

45
Exam New Patients
  • A complete list of exam bullets can be found in
    the 1997 Documentation Guidelines for Evaluation
    Management Services (developed jointly by the
    AMA HCFA).

46
Coding of Problem Visits New Patients
  • Following is a list of the number of exam bullets
    that corresponds to the level of office visit to
    code for new patients
  • 1 to 5 exam bullets 99201 or W9201 Brief
  • 6 to 11 exam bullets 99202 or W9202 Expanded
  • 12 to 17 exam bullets 99203 or W9203 Detailed
  • 18 to 23 exam bullets 99204 or W9204
    Comprehensive
  • A comprehensive office visit has the same
    requirements as full preventive visit (per the
    preventive guidelines in the PHPR). If this level
    of exam is performed, the provider should look at
    coding a full preventive exam on the patient.
  • 24 or more bullets 99205 or W9205 Complex
  • Comprehensive and Complex levels of new patient
    visits should seldom occur in a health department
    site. These have been addressed here in case of
    rare emergencies.

47
Coding of Problem Visits New Patients
  • The AMA expects medical providers to do a more
    thorough exam, within reason, on a new patient to
    provide a good base line for future visits (see
    907 KAR 3130).

48
Coding of Problem Visits New Patients
  • Coding for new patients is directly related to
    the amount of exam bullets performed.
  • Count the number of exam bullets and code
    accordingly.

49
Coding of Problem Visits
  • Established Patients

50
Coding of Problem Visits Established Patients
  • To code a Problem Visit for an established
    patient, the AMA requires that only two of the
    three components be documented.
  • History
  • Exam
  • Decision making
  • The visit should be coded by the lowest of the
    two components.

51
Coding of Problem Visits Established Patients
  • The level of visit chosen for established
    patients will be driven by the lowest of either
    the history component or the medical decision
    making component.
  • Exam performed should be what is required by
    protocol and medically necessary.

52
Coding of Problem Visits Established Patients
  • 99211 and W9211 Brief
  • No history is taken
  • Decision making is minimal
  • No ROS (review of systems)
  • Examples
  • Daily Rx or OTC medication administration to
    patients who have
  • One stable chronic illness well controlled
    (minimal risk)
  • i.e. Ritalin, Tegretol, Singulair
  • One previously diagnosed acute uncomplicated
    illness or injury (minimal risk)
  • i.e. amoxicilin, eye drops

53
Coding of Problem Visits Established Patients
  • 99212 or W9212 Limited
  • Requires at least 2 of these 3 key components
  • Problem specific history
  • Straight forward decision making
  • ROS
  • Patients who have one or more self-limited or
    minor problem(s)
  • Examples
  • Headache
  • Upset stomach
  • Head lice (either suspected or found)
  • Earache
  • Menstrual cramps
  • Vaccines (no apparent contraindications)
  • Daily Rx or OTC medication administration with a
    complaint/problem i.e. Ritalin, Singulair,
    amoxicilin

54
Coding of Problem Visits Established Patients
  • 99213 or W9213 Expanded
  • Requires at least 2 of these 3 key components
  • Expanded problem focused history
  • Expanded problem focused examination
  • Decision making of low to moderate complexity
  • Examples
  • Daily Rx medication administration to patients
    who have one stable chronic illness (i.e.
    insulin)
  • Injuries that require the patient to go home
  • Medication unavailable and coordination of care
    with parent or physician is necessary

55
Coding of Problem Visits Established Patients
  • 99214 or W9214 Detailed
  • Requires at least 2 of these 3 key components
  • Detailed history
  • Detailed examination
  • Decision making of moderate complexity
  • Presenting problems are of moderate to high
    complexity
  • Examples
  • Patients who experience exacerbation of chronic
    illnesses (i.e. diabetes, asthma, ADHD,
    epilepsy)
  • Patients who present with acute uncomplicated
    problems requiring more care coordination (i.e.
    broken bones, emergency room, stitches, adverse
    reactions)

56
Coding of Problem Visits Established Patients
  • 99215 or W9215 Comprehensive
  • Requires at least 2 of these 3 key components
  • Comprehensive history
  • Comprehensive examination
  • Decision making of high complexity
  • Presenting problems are of moderate to high
    complexity
  • Significant risk to the life of the patient
  • Examples
  • Severe or prolonged seizures
  • Diabetic coma
  • Head injuries with prolonged unconsciousness or
    abrupt neurological changes
  • Emergency treatment necessary via EMS

57
  • Multiple Visits for the Same Patient on the Same
    Day

58
Multiple Visits for the Same Patient on the Same
Day with Same Problem
  • If a patient presents to the local health
    department satellite school site more
    than one time on the same day for the same
  • problem, only one Office Visit (OV) can be
    billed
  • Each visit must be documented in the patients
    medical record
  • If a patient is seen multiple times for the same
    problem on the
  • same day, following the last visit of the day,
    the nurse should
  • review the documentation and select the most
    complex visit
  • and submit that PEF for the appropriate level
    of billing

59
Multiple Visits for the Same Patient on the Same
Day with Different Problem
  • If a patient presents to the local health
    department satellite school site more than once
    on the same day for two or more different
    problems, a PEF shall be initiated for each of
    the visits
  • The visits should be coded according to the
    guidelines that have been listed previously
  • Medicaid is not recognizing Modifiers at this
    time.

60
Multiple Visits for the Same Patient on the Same
Day with Different Problem
  • The first PEF will report a visit (no modifier 25
    is used)
  • The subsequent PEF should have a visit reported
    along with Modifier 25
  • Modifier 25 is used when patients are seen for a
    separate identifiable service by the same
    provider on the same date

The 25 modifier is located beneath the Other Then
Preventive codes section. You may either check
or circle the 25.
61
Miscellaneous
62
Records
  • Local Health Department Satellite School Site
    records may follow students from school to school
    within the same county.
  • A Master Patient index MUST be kept at every
    health department school site clinic so that
    records can be located when needed.
  • When a student leaves the system or graduates,
    the record should be returned to the local health
    department regular clinic site.
  • See Administrative Reference Medical Records

63
Mass screenings
  • Mass screenings such as hearing and vision or
    scoliosis are not billable and should not be
    reported on a PEF.

64
Local Health Dept. Support Staff
  • Permission to treat should be obtained before
    patients are seen in health department satellite
    school site.
  • Health Department support staff working in local
    health department satellite school sites cannot
    provide medical services to patients.
  • School employees delegated responsibility by
    healthcare personnel are covered by law if they
    provide these types of services, but health
    department support staff are not covered under
    this law however, if the local health department
    insurance policy covers support staff for
    delegated activities that is acceptable.

65
Billing
  • Patients ages 3 through 20 will not incur a
    self-pay charge if they are seen in a health
    department satellite school site.
  • Medicaid will be billed for those who are
    eligible.
  • See 902 KAR 8170
  • IEP Services
  • The Dept. for Medicaid Services does not allow
    any service for an IEP Student to be billed
    through the PT20 Preventive Program. All IEP
    Services must be billed through PT21 School Based
    Services. See 702 KAR 3285

66
Level of Care (Level 8B)
  • The Level of Care Tool is effective for Health
    Department clinic coding ONLY.
  • We cannot use this tool for coding in the Local
    Health Department Satellite School Sites.

67
HUMANA INSURANCE
  • As of July 17, 2009 it is no longer allowable to
    bill Humana Insurance from a local health
    department satellite school site.
  • Services rendered to insurance patients must
    still be entered into the PSRS using the skip
    in the insurance field.
  • Health Department Clinic sites may continue to
    bill for Physician and mid-level provider
    services. Services performed by nurses may not
    be billed for any code above a 99211.

68
Guiding Principles
  • Only provide the level of care that is medically
    necessary.
  • Always provide and document services in
    accordance with the Public Health Practice
    Reference and with established best practices.
  • Always code and document exactly what care was
    provided.

69
CONTACT INFORMATION
  • For any questions related to this material,
    please contact
  • Local Health Operations(LHO) Help Desk via
  • Phone (502) 564-6663 Option 5
  • Email localhealth.helpdesk_at_ky.gov
  • Also, please see the new LHO Website _at_
  • http//chfs.ky.gov/dph/info/lhd/lhob.htm

70
References
  • Current Procedural Terminology 2009
  • International Classification of Disease 9th
    Revision 2009
  • 1995 CMS document Documentation Guidelines to
    Evaluation Management Services
  • 1997 CMS document Documentation Guidelines to
    Evaluation Management Services
  • CMS Evaluation Management Service Guide
  • NASN Role of School Nurse in Third Party
    Reimbursement
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