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Coding for Local Health Department Clinic

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Coding for Local Health Department Clinic & School Sites Presented by: Cynthia H. Robinson Kentucky Department for Public Health AFM/LHO July 2011 – PowerPoint PPT presentation

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Title: Coding for Local Health Department Clinic


1
Coding for Local Health Department Clinic
School Sites
  • Presented by Cynthia H. Robinson
  • Kentucky Department for Public Health
  • AFM/LHO
  • July 2011

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
  • 7. Multiple Visits for the Same Patient on the
    Same Day

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

4
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.

5
Coding on the PEF
6
Coding on the PEF
  • The state-updated CH-45 (PEF) is used in most
    health department clinics. (Shown on next slide.)
  • Some health departments prefer to create and use
    an abbreviated PEF at off site clinics (e.g. Flu
    Clinics School sites). This is entirely
    permissible.
  • Health Departments using their own forms are
    responsible for keeping these forms up-to-date.

7
(No Transcript)
8
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.

9
Examples of Codes
CPT codes - WHAT
ICD-9 codes - WHY
  • CLINIC SETTING
  • 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.
  • 99393 Periodic comprehensive preventive
    medicine reevaluation management of an
    individual late childhood (age 5 through 11
    years)
  • SCHOOL SETTING
  • 99212 Office or other outpatient visit for the
    E/M of an established patient, which requires at
    least 2 of these 3 key components History, exam,
    medical decision making
  • V741 Special Screening Examination For
    Pulmonary Tuberculosis
  • V202 - Routine Infant Or Child Health check
  • 7840 Headache Facial Pain Pain in
    head NOS

10
Coding E/M visits on the PEF
  • Coding E/M visits in health department clinics
    consists of
  • Preventive Visits E/M visits (e.g. well child
    exam, well woman checks)
  • Evaluation/Management visits, which LHDs
    commonly refer to as problem visits (e.g.
    supply visits, STDs, cancer screenings)

11
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

12
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

13
Coding on the PEF Provider Level
  • REMEMBER
  • 992 codes - for use by physicians and mid level
    providers only
  • W92 codes - for use by nurses (RNs)
  • Physicians and mid level providers code in the
    upper portion of the Preventive and Other Than
    Preventive Sections.
  • Nurses code in the lower portion of the
    Preventive and Other Than Preventive Sections.

14
Coding on the PEF- CPT codes
  • CPT codes for lab tests, 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
    should be written in the area provided

15
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.

16
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 preventive exam by a nurse (V202-) and
    also receives vaccines (V069-).
  • This would be coded on the preventive side of the
    PEF

V202-
v
V069-
17
ICD Codes In Health Department Sites
  • ICD codes are revised annually and are effective
    on October 1 of each year.
  • ICD9 is changing to ICD10 effective October 1,
    2013.
  • Many LHDs create their own listing of most
    commonly used ICD codes.
  • REMEMBER These lists must be updated annually.

18
Determination of New or Established Patients
19
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.

20
New Established Patients
  • NEW PATIENT - a patient who has not received a
    profession service (i.e., preventive, problem
    focused, or procedure) 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.

21
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 site itself,
    often making it difficult for the provider to
    know whether the patient is new or established.

22
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.

23
New Established Patients Clinic Setting If
the system is down or off-site
  • Patient presents to nurse requesting pregnancy
    test
  • 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


V7241
v
v
24
New Established Patients School Setting
  • 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
25
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
    slides).
  • The provider must determine the level of visit.

26
Coding of Preventive Visits
27
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

28
Refresher on Existing Code
  • 82270 Hemocult (fecal occult blood)
  • qualitative feces, consecutive collected
    specimens with single determination, for
    colorectal neoplasm screening(i.e., pt was
    provided 3 cards or single triple card for
    consecutive collection
  • The description of this code includes all three
    cards, therefore it would only be coded one unit
    for this test. Pt has to bring back at least one
    to three cards to be able to code 82270.

29
Components for coding Other than Preventive E/M
Visits
  • Commonly Referred to as Problem Visits in
    Health Department Settings

30
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.

31
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

32
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

33
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

34
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

35
Coding of Problem Visits
  • New Patients

36
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.

37
Coding of Problem Visits New Patients
  • The exam component will be the lowest of the
    three components 99 of the time.
  • New patients should 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).

38
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

39
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).

40
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.

41
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).

42
Coding of Problem Visits New Patients
  • Remember to have some History, some decision
    making, however the Coding for new patients is
    directly related to the amount of exam bullets
    performed, as its usually the lowest component
    in HD.
  • Count the number of exam bullets and code
    accordingly.

43
Coding of Problem Visits
  • Established Patients

44
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.

45
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.

46
Coding of Problem Visits Established Patients
(Clinic)
  • 99211 and W9211 Brief
  • No history is taken
  • Decision making is minimal
  • No ROS (review of systems)
  • Examples
  • Negative TB skin test reading
  • (NEVER write a SOAP note for a negative TB skin
    test reading. That raises the level of visit
    and is never medically necessary.)

47
Coding of Problem Visits Established Patients
(School)
  • 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

48
Coding of Problem Visits Established Patients
(Clinic)
  • 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
  • Supply Visit (no complaints or problems)
  • STD Visit (no problems or negative results)
  • Head lice (either suspected or found)

49
Coding of Problem Visits Established Patients
(School)
  • 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
  • Daily Rx or OTC medication administration with a
    complaint/problem i.e. Ritalin, Singulair,
    amoxicilin

50
Coding of Problem Visits Established Patients
(Clinic)
  • 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
  • Pt to receive depo wt gain 5 lb since last
    visit, c/o occasional headaches counseled
    depo adm.
  • Positive TB skin test reading
  • Positive STD visit with treatment
  • Daily Rx medication administration to patients
    who have one stable chronic illness w/o problems
    (i.e. DOT Communicable Disease)

51
Coding of Problem Visits Established Patients
(School)
  • 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

52
Coding of Problem Visits Established Patients
(Clinic)
  • 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
  • True contraindication to contraceptive methods
  • OCs - B/P 160/92, c/o severe HAs daily with
    visual impairment - no contraceptive given until
    patient is further evaluated
  • Patients presenting with problems significant
    enough that more case management is necessary
  • Pt with abnormal breast exam
  • Please keep in mind 907 KAR 3010 Section
    4
  • PHYSICIANS MEDICAID only pays Doctors for TWO
    99214 visits per 12 months

53
Coding of Problem Visits Established Patients
(School)
  • 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)
  • Please keep in mind 907 KAR 3010 Section
    4
  • PHYSICIANS MEDICAID only pays Doctors for TWO
    99214 visits per 12 months

54
Coding of Problem Visits Established Patients
(Clinic)
  • 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
  • HIV
  • Rape
  • Abrupt neurological changes
  • Anaphylactic reaction to vaccine
  • Emergency treatment necessary via EMS
  • Please keep in mind 907 KAR 3010 Section
    4
  • PHYSICIANS MEDICAID only pays Doctors for TWO
    99215 visits per 12 months

55
Coding of Problem Visits Established Patients
(School)
  • 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
  • Please keep in mind 907 KAR 3010 Section
    4
  • PHYSICIANS MEDICAID only pays Doctors for TWO
    99215 visits per 12 months

56
  • Multiple Visits for the Same Patient on the Same
    Day

57
Multiple Visits for the Same Patient on the Same
Day with Different Problem (Clinic)
  • A 25 modifier may be reported with a Preventive
    visit, if there is a significant enough and
    separately identifiable problem . The 25 modifier
    would be listed with problem-focused E/M visit.
  • When immunizations are given, problem-focused E/M
    with a 25 modifier may be reported if there is a
    distinct and separately, identifiable reason for
    the E/M visit (i.e., a different diagnosis code).
  • When an E/M is reported on the same day as
    another procedure , such as a MNT the E/M will
    require a 25 modifier and the diagnosis code for
    the E/M needs to different from the diagnosis
    code for the MNT.

OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL OTHER THAN PREVENTIVE HEALTH CHECK E/M -PHYSICIAN/MID LEVEL
? CPT NEW Visit Type ? CPT EST. Visit Type PROVIDER
99201 Brief 99211 Brief
99202 Expanded 99212 Limited
99203 Detailed 99213 Expanded
99204 Comprehensive 99214 Detailed ICD (P)
99205 Complex 99215 Comprehensive
25 MODIFIER Separate E/M by same provider/same day 25 MODIFIER Separate E/M by same provider/same day 25 MODIFIER Separate E/M by same provider/same day 25 MODIFIER Separate E/M by same provider/same day
? NURSE NURSE NURSE ICD (S)
W9201 Brief W9211 Brief
W9202 Expanded W9212 Limited
W9203 Detailed W9213 Expanded REF/DISP
W9204 Comprehensive W9214 Detailed
W9205 Complex W9215 Comprehensive
The 25 modifier is located beneath the Other Then
Preventive codes section. You may either check
or circle the 25.
58
Example of when to use the 25 Modifier
  • 39 year old established pt comes in for Family
    Planning preventive visit, while doing this pts
    family planning preventive visit, the APRN finds
    vaginal warts, and with the permission of the pt,
    treats.
  • Coding would consist of
  • 99395
  • 9921325

59
Another Example of when to use the 25 Modifier
  • 17 year old established pt comes in for family
    planning supplies and RN finds out she has not
    received the Gardasil vaccine. Pt wants to
    receive this vaccine and is counseled per
    component.
  • Coding would consist of
  • 9921225
  • 90460 1unit
  • 90649

60
Multiple Visits for the Same Patient on the Same
Day with Different or Same Problem (School)
  • If a patient presents to the local health
    department satellite school site
    more than one time on the same day for a
    different or same problem, only one Office Visit
    (OV) can be billed per Medicaid
  • However, each visit must be documented in the
    patients medical record
  • If a patient is seen multiple times for the
    different or 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

61
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.

62
References
  • Current Procedural Terminology 2011
  • International Classification of Disease 9th
    Revision 2011
  • 1995 CMS document Documentation Guidelines to
    Evaluation Management Services
  • 1997 CMS document Documentation Guidelines to
    Evaluation Management Services
  • CMS Evaluation Management Service Guide
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