ICD-9, CPT, E&M Coding Documentation and Compliance …or the in-service for the in-service!!
…You’ve just seen a patient in your office… • …and after the exam • You want to get paid • (After all, you need to pay mortgage, food, etc) • Insurance will pay you if… • You tell the company what you did…AND… • You tell the company why you did it
Types of “Codes” • Procedure codes • What I did during the visit • Two Types • CPT • Evaluation and Management • ICD • Why I did it • The actual diagnosis code • …and these must make sense together
ICD codes ICD-9
ICD Codes • ICD = International Statistical Classification of Diseases and Related Health Problems • Provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. • Every health condition can be assigned to a unique category and given a code, up to six characters long. • Easy to understand • Allows for global (international) understanding of information
ICD-9 (9th version- currently one in use) • 001-139: Infectious and parasitic diseases • 140-239: Neoplasms • 240-279: Endocrine, nutritional, metabolic and immunity disorders • 280-289: Blood ad blood-forming organs • 290-319: Mental disorders (used by primary care and psych for research. DSM codes are used for clinical billing by psych) • 320-359: Nervous system • 360-389: Sense organs • 390-459: Circulatory system • 460-519: Respiratory system • 520-579: Digestive system • 580-629: Genitourinary system • 630-676: Complications of pregnancy/childbirth • 680-709: Skin and subcutaneous tissues • 710-739: Musculoskeletal system and connective tissue • 740-759: Congenital anomalies • 760-779: Certain conditions originating in the perinatal period • 780-799: Symptoms, signs and ill-defined conditions • 800-999: Injury and poisoning • E and V codes: External causes of injury and supplemental classification
ICD-9 • Can list by disease or symptom • Get better reimbursement for more detail • Some insurances will only pay for a certain number of visits per diagnosis • e.g., diabetes • Large book with diagnostic codes or can get on line • http://www.icd9coding1.com/flashcode/home.jsp
ICD-9 codes More detail the better…. Break these down further!
Diseases of the circulatory system (390-459) • Hypertensive disease (401-405) • (401) Essential Hypertension • (401.0) Hypertension, malignant • (401.1) Hypertension, benign • (402) Hypertensive heart disease • (403) Hypertensive renal disease • (403.91) Hypertensive renal disease, unspec., w/ renal failure • (404) Hypertensive heart and renal disease • (405.01) Hypertension, renovascular, malignant • (405.11) Hypertension, renovascular, benign
Endocrine, nutritional and metabolic diseases, and immunity disorders (240-279) • diseases of other endocrine glands (250-259) • Note: for 250-259, the following fifth digit can be added: • (250.x0) Diabetes mellitus type 2 • (250.x1) Diabetes mellitus type 1 • (250.x2) Diabetes mellitus type 2, uncontrolled • (250.x3) Diabetes mellitus type 1, uncontrolled • (250) Diabetes mellitus • (250.0) Diabetes mellitus without mention of complication • (250.1) Diabetes with ketoacidosis • (250.2) Diabetes with hyperosmolarity • (250.3) Diabetes with other coma • (250.4) Diabetes with renal manifestations • (250.5) Diabetes with ophthalmic manifestations • (250.6) Diabetes with neurological manifestations • (250.7) Diabetes with peripheral circulatory disorder • (250.8) Diabetes with other nonspecified manifestations • (250.9) Diabetes with unspecified complication
(780) General symptoms (780.0) Alteration of consciousness (780.01) Coma, nondiabetic, nonhepatic (780.02) Mental status changes (780.09) Semicoma, stupor (780.1) Hallucinations (780.2) Syncope (780.3) Convulsions (780.31) Seizures, convulsions, febrile (780.39) Seizures, convulsions, other (780.4) Dizziness/vertigo, NOS (780.5) Sleep disturbance, unspec. (780.53) Hypersomnia, sleep apnea (780.53) Sleep apnea w/ hypersomnia (780.58) Movement disorder, sleep related (780.6) Fever, nonperinatal (780.7) Malaise and fatigue (780.8) Sweating, excessive (780.9) Other general symptoms (780.92) Crying, infant, excessive (780.93) Memory loss (780.94) Early satiety 780-799: Symptoms, signs and ill-defined conditions
CPT Current Procedural Terminology
CPT • CPT = Current Procedural Terminology • Code Set accurately describes medical, surgical, and diagnostic services • Designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. • The current version is the CPT 2008.
CPT • A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. • There are approximately 7,800 CPT codes ranging from 00100 through 99499. • Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure.
Current Procedural Terminology • Chapter 1: Evaluation and Management Codes (99201-99499) • Chapter 2: Anesthesia Codes (00100-01999) • Chapter 3: Surgery Codes (10040-69990) • Chapter 4: Radiology Codes (70010-79999) • Chapter 5: Pathology/Laboratory Codes (80049-89399) • Chapter 6: Medicine Codes (90281-99199) • Appendices: Modifiers, Deleted codes
V codes: Supplemental classification • V01 Contact with or exposure to communicable diseases • V02 Carrier or suspected carrier of infectious diseases • V09 Infection with drug-resistant microorganisms • V10 Personal history of malignant neoplasm (i.e. cancer) • V16 Family history of malignant neoplasm • V17 Family history of certain chronic disabling diseases • V20 Health supervision of infant or child • V21 Constitutional states in development • V22 Normal pregnancy
V codes, cont • V23 Supervision of high-risk pregnancy • V24 Postpartum care and examination • V25 Encounter for contraceptive management • V28 Encounter for [antenatal] screening of mother • V29 Observation and evaluation of newborns for suspected conditions not found • V30 Single liveborn • V31 Twin birth mate liveborn • V48 Problems with head neck and trunk • V49 Other conditions influencing health status • V50 Elective surgery for purposes other than remedying health states • V51 Aftercare involving the use of plastic surgery
V codes, cont • V56 Encounter for dialysis and dialysis catheter care • V57 Care involving use of rehabilitation procedures • V58 Encounter for other and unspecified procedures and aftercare • V60 Housing, household and economic circumstances • V64 Persons encountering health services for specific procedures not carried out • V65 Other persons seeking consultation • V66 Convalescence and palliative care • V67 Follow-up examination • V68 Encounters for administrative purposes • V69 Problems related to lifestyle • V70 General medical examination • V71 Observation and evaluation for suspected conditions not found • V80 Special screening for neurological eye and ear diseases • V81 Special screening for cardiovascular respiratory and genitourinary diseases • V85 Body mass index
Relationship between CPT and ICD-9 • The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. • Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. • For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD-9 826.0, closed fracture of a phalanges of the foot. • Such a claim would be quickly identified and rejected.
…trivia for boards… • Health Care Financing Administration (HCFA) • Common Procedural Coding System (HCPCS) • Diagnosis Codes ICD – 9 • Creates medical necessity • Level I CPT • Updated Annually • Level II (national) HCPCS (A-V) • Alphanumeric System • Level III (State) Local Codes (W-Z)
E & M Coding Evaluation and Management Most confusing for physicians
What are E&M Codes? • The Evaluation & Management (E&M) codes are a sub-set of the CPT codes. • Can be used by all privileged providers • Describes: • Complexity of care provided to a patient for non-procedural visits. • The place of service (inpatient or outpatient) • The type of service (new vs. established, consult, preventive, ER, critical care, etc) • Defined by 3 components • The patient history • The physical examination • Medical decision making
Why Code? • REIMBURSEMENT • Third Party Payers/Insurance Agencies • Prospective Payment Systems (PPS) • Over coding = Fraud • Under coding = Lost Revenue
What Do Coders Look For? • Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing information • It is the Content, not the volume, of documentation that determines your E&M code!
What Do Coders Look For? • Every patient encounter should be legible and include: • Date of Encounter • Reason for the visit (chief complaint) • Appropriate history of present illness • An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent) • Review of lab, x-ray, other ancillary services when appropriate • Assessment • Plan of care/Treatment options • Provider signature
Why is Documentation Important? • The documentation must support the E&M code you select. • Your documentation must also support the medical necessity of the services provided. • The first step is to clearly document the reason for every visit – the chief complaint. • The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity. • However it is acceptable to document “Follow-up for _____”. • “If it isn’t documented, it wasn’t done!”
Patient Type New vs. Established Consult Inpatient vs. Outpatient
New vs. Established • New patient • Any patient who has not received professional services, within the previous 36 months, from a provider within the same group, of the same specialty • Same group practice: One Federal Tax ID number for all providers, if more than one Federal Tax ID, can consider the patient new • e.g., current practice seen in OLBH ER and Outreach offices • Professional Services: Phone call, prescription, hospital or office visit, etc. • Specialty Issue: Optional if one federal Tax ID is shared by practitioners of other specialties (e.g., surgeon and FP) • ** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO
Average and Recommended Code Distributions The difference in the bell curves represents loss in physician income!!
Determining the Correct E&M Code • There are three key components to consider when selecting the appropriate E&M: • History • Exam • Medical Decision Making (MDM) • All three components must be documented for a newpatient (new to clinic or not seen within the past three years). Indicate in CC if patient is new. • Only two of the three components must be documented for established patients (seen within the past three years). • E&M selection should never be based on the allotted time on the appointment schedule!
Determining the Correct E&M Code • To determine the correct level E&M code, consider the complexity of your patient’s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam. • Remember: • For a new clinic patient, initial consult, initial inpatient visit or ED encounter you must document all three key components • history, exam and your medical decision making.
Defining Levels of E&M Services • 7 components • History • Examination • Medical Decision Making • Counseling • Coordination of care • Nature of Presenting Problem • Time
History • Also has several components to determine “complexity” or “type” • History of Present Illness (HPI) • Review of Systems (ROS) • Past Family and/or Social History (PFSH) • The extent of history is dependent on clinical judgment and the nature of the presenting problem. • The four types of History include: Problem focused, Expanded Problem Focused, Detailed and Comprehensive.
History – Chief Complaint • Chief Complaint Required • concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. • The CC is usually stated in the patient’s own words. • For example, patient complains of upset stomach, aching joints, and fatigue • Cannot be the words “follow up” alone
History – History of Present Illness • Two types of HPI • Brief, which includes documentation of one to three HPI elements. • In the following example, three HPI elements – location, severity, and duration – are documented: • CC: A patient seen in the office complains of left ear pain. • Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.
History – History of Present Illness • Extended, which includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions. • In the following example, five HPI elements – location, severity, duration, context, and modifying factors – are documented: • Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.
History Components • Location • Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referred • Quality • Specific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worsening • Laceration as jagged or straight • Sore throat as scratchy • Severity • Pain scale, “compared to”, observation by physician (discomfort, wincing) • Duration
History Components • Timing • Onset of problem or symptom and progression, recurrent, comes and goes, worsens or improves • Context • Associated with activity, improves with activity, etc • Modifying factors • Steps the patient has taken to alleviate symptoms, what exacerbates symptoms, is helped by, is hindered by • Associated signs/symptoms • Clinical impressions direct physician questioning • Specific symptoms (weakness, headache with injury) • Generalized symptoms, chills, fever, “pertinent positives and negatives”
History Guidelines • HPI must be documented by the physician • ROS and/or PFSH can be recorded by ancillary staff • Physician must supplement or confirm the information • If obtained at a prior visit, do not need to re-record. Can review and update • Describe new information • Note date and location of earlier information
History Guidelines • If unable to obtain a history • Describe patient’s medical condition or circumstance which precludes obtaining a history
Review of Systems • Definition • An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced • The following “systems” are recognized: • Constitutional (fever, weight loss) - Psychiatric • Eyes - Endocrine • Ears, nose, mouth throat - Neurological • Cardiovascular - Allergic/Immunologic • Respiratory • Gastrointestinal • Musculoskeletal • Integumentary (skin and/or breast) • Hematologic/Lymphatic
Review of Systems • Three categories of review • Problem Pertinent • ROS inquires about the system directly related to the problem(s) identified in the HPI • Both positive responses and pertinent negatives should be documented • In the following example, one system – the ear – is reviewed: • CC: Earache. • ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.
Review of Systems • Extended • ROS inquires about the system directly related to HPI AND a limited number of additional systems • 2-9 systems which are documented • In the following example, two systems – cardiovascular and respiratory – are reviewed: • CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.” • ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.
Review of Systems • Complete • ROS inquires about the system directly related to the HPI AND all other body systems • At least 10 body systems must be documented • Those systems w/pertinent +or- responses must be individually documented, however for the remaining systems, “all other systems are negative” is permissible
Review of Systems • In the following example, 10 signs and symptoms are reviewed: • CC: Patient complains of “fainting spell.” • ROS: • Constitutional: weight stable, + fatigue. • Eyes: + loss of peripheral vision. • Ear, Nose, Mouth, Throat: no complaints. • Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema. • Respiratory: + shortness of breath on exertion. • Gastrointestinal: appetite good, denies heartburn and indigestion. • + episodes of nausea. Bowel movement daily; denies constipation or loose stools. • Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort. • Skin: + clammy, moist skin. • Neurological: + fainting; denies numbness, tingling, and tremors. • Psychiatric: denies memory loss or depression. Mood pleasant.
Past Medical History Medical Family Social
History - PFSH • Past History • Past experience with illnesses, operations, injuries and treatments • Family History • Review of medical events in patients family, including hereditary disease • Social History • Age appropriate review of past and current activities