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.

9. 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. Codes

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

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

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. 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. Coding on the PEF – Provider Level • 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- √ 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-- √

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- √ √

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 patient’s 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- √

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 ofProblem 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 patient’s 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 3:130).

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.