NP Office Coding

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NP Office Coding
STUMPERS (aka jeopardy)

• On loan from
• Allen Daugird, MD, MBA
• UNC Dept of Family Medicine
• May 2003

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Coding STUMPERS!
Paid for Thinking
Using Your Hands
Whats in a Name?
Prevention Counts
Grab Bag
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STUMPERS!
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E M Codes
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What are Evaluation and Management Codes for
office visits?

• Used for cognitive services -i.e. most of our
  office visits

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History, PE, Medical Decision Making
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What are the three major components of EM
services?

• Look at the grids (pp 2-3) at the front of your
  handouts
• These major components determine the level of the
  EM CPT code

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Patient who has never been seen in your office or
the last time was longer than 3 years ago
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What is a new patient?

• This is crucial in deciding which set of EM
  codes to use
• Reimbursement higher for new codes

a6a
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35 minutes of total of 40 minutes of office visit
for established patient used in counseling
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What is a 99215 visit?

• When more than 50 of EM visit is for face to
  face counseling or coordination of care, time can
  be the primary determinant of the code
• Have to document the time (note just like in the
  Jeopardy question) in the along with a
  description of the issues counseling was about
• See times in far right column of grids
• CANNOT use for MCR incident to billing

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CPT Code for Brief HPI, 5 organ systems PE,
moderate complexity decision making in an
established patient
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What is a 99214 office visit?

• Only need 2 of the 3 major components to support
  the EM code level for established patients
• BUT need 3 of 3 for new patient codes

a10a
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Freezing warts, injecting trigger points,
excising moles
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What are office procedures?

• Almost anything you do with your hands (vs. your
  brain) has a separate CPT code

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Code for Ear Wax Removal
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What is CPT code 69210?

• Almost anything you do with your hands (vs. your
  brain) has a separate CPT code
• Even though the office nurses usually do this, we
  can still bill for it (it is done incident to
  your services and under your supervision)

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Code you use when providing both separately
identifiable EM service AND a procedure
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What is Modifier -25 at end of EM code?

• you have to have documentation for both the EM
  code and the procedure
• usually best if EM services are for different
  diagnosis than procedure
• YOU must circle the -25 modifier on the
  encounter form

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Simple surgical procedures which do not have a
global period and for which you DO charge for any
post-op visits
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What are starred procedures?

• See description at beginning of Surgery section
  of CPT book
• Can charge for separate EM services if provided
  (use 25 modifier)

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CPT Codes you would use for giving 100mg
meperidine IM
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What are 90782 AND J2175

• When giving injections remember to charge for the
  supply of the drug itself (J codes)

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ICD-9 Codes
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What set of codes is used for diagnoses?

• International Classification of Diseases, 9th
  revision, Clinical Modification
• Adopted by HCFA, changes yearly
• Major new version in the works
• See primary care short list pp 5-6

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Thousands and Thousands
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How many ICD9 codesare there?

• The book is thick
• Organized by Organ System
• May start in index, but need to read the actual
  table for exclusions, etc
• You can find a diagnosis code for most everything
  by using the list on pp 5-6 (Available at
  www.aafp.org and updated annually in Oct)

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Writing down 250 as shorthand for diabetes code
250.00
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What is inadequate diagnosis coding?

• Have to code ICD9 codes down to all available
  digits
• Codes can be 3, 4, or 5 digits

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Diagnosis codes used for prevention, screening,
contraception
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What are V codes?

• Whole list of V codes to describe non-illness
  situations
• Many insurers will not pay for services when only
  these codes are used (including Medicare!)

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Diagnosis you would use for patient with nausea
but no vomiting when the cause is not yet clear
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What is 787.02?

• There are a whole set of symptom ICD9 codes you
  can use when the diagnosis is not yet clear
• Very helpful in primary care for initial
  presenting complaints
• Beware of negative impact on patients
  insurability if you use disease diagnosis code
  (vs. symptom) that turns out to be wrong

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CPT Codes 99381-99397
d2
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What are the prevention CPT codes?

• Age grouped codes
• Medicare will NOT pay for these (MCR HMOs might)
• NC State Employees Health Plan you must use
  these and V70.0 ICD9 code for the deductible to
  be waived
• Comprehensive Hx, Comp PE (lt than in other
  EMs), counseling, lab

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V70.0
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What is the diagnosis code used for adult
wellness exams?

• May also use v72.3 for gyn exam, v25.01 for oral
  contraception, etc
• Use V76.2 for MCR screening breast/pelvic exam
  (special screening for malignant neoplasms,
  cervix)

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Daily Double

• Make a Wager

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HealthCheck
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What is the Well Child Check visit program for NC
Medicaid?

• Medicaid has its own set of special codes and
  rules
• Rules are complex, and may want to consider using
  a special encounter form
• Reimbursement is excellent and worth the hassle

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A Medicare patient who comes in with no medical
problems and just wants a physical
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What is an uncovered service under Medicare?

• Uncovered services do not need a waiver form
  signed, but you should discuss w/ the patient
  BEFORE providing services and see if they agree
  to pay themselves (pp 15-16)
• In reality this is unusual for most Medicare
  patients-they usually have some symptoms or
  illness (remember menopause, osteoarthritis, etc)
• MCR will pay for breast/pelvic exam q 2y

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The CPT code type you would use for a woman
coming in for a Pap, but who has new complaints
of severe headaches and chest pain, which you
evaluate treat
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What is an office visit EM code

• Prevention codes do not cover significant medical
  problems
• You can use both a prevention code and EM code
  with modifier 25, but usually an EM code is used
  (would have to have documentation to support both)

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A CPT code AND an ICD9 code
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What are needed for every encounter form

• Insurance company computers will reject claims
  without both

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An ICD9 Code that supports each CPT code
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What is needed for every encounter form

• Insurance claims are submitted electronically
• Its one computer talking to another
• A CPT code will not get paid unless there is a
  diagnosis code supporting it (i.e. the insurance
  computer has logic that will only pay for the CPT
  code if it finds certain ICD9 codes that it
  thinks justify it)

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Billing for NP services under a physician name
and provider ID
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What is incident to billing?

• The way most commercial insurance is billed for
  NP services
• An option for MCR MCD, but have to follow their
  rules for incident to (pp 10-13)
• NPs can bill MCR/MCD directly, but will get only
  85 of MCR fee

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An EM code physician/NP/CNM should never use
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What is a 99211?

• This almost always is for nursing only visits
• Look at the grid for 99212 almost any clinician
  encounter will fulfill the criteria

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CPT codes used for an established patient whom
you evaluate for abdominal pain (Detailed Hx
PE) and also do anoscopy on
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What are 99214-25 AND 46600?

• Need only 2 of 3 components for established
  patient EM codes
• Use -25 modifier after CPT code to tell insurer
  you did EM service separately in addition to
  procedure

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Final Stumpers!
Make a Wager
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Final Stumpers Answer

• modifier -51

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What modifier is used when multiple procedures
are done on the same day
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