Transcript Rehabilitation Management

Coding, Documentation, and
Data Management
Kyle C. Dennis, Ph.D.,
Deputy Director, Audiology &
Speech Pathology Service
Department of Veterans Affairs
Session Objectives
Understand basic code systems
Understand basic organization and principles of
procedure and disease coding
Understand basic principles of coding and billing
Understand basic principles of documentation
Topics for Discussion
Coding systems
Procedure codes
Disease codes
Coding, billing, and compliance
Documentation
Referral guidelines and service
agreements
How are codes used?
Revenue generation (reimbursement)
Documentation of services
Workload and utilization
Productivity
Cost analysis
Provider profiles (privileging)
Analysis, health research, and trending
Coding Systems
Procedure Coding Systems
Healthcare Common Procedure Coding
System (HCPCS)
Current Procedural Terminology (CPT)
HCPCS Level II (National or HCPCS)
ICD-9 PCS
Future: ICD-10-CM and ICD-10 PCS
Disease Coding
International Classification of Diseases,
Ninth Edition, with Clinical Modifications
(ICD-9-CM)
Future: International Classification of
Diseases, Tenth Edition (ICD-10-CM)
Professional & Technical
Codes may not have physician work value
Some codes have technical (TC) and
professional (26) components.
Professional component=physician work
(May be billed by audiologists.)
Technical component=practice expense
Most Audiology codes do not have
physician work.
Complexity-based Codes
Unless otherwise specified, procedures
are based on complexity
Enter one code per procedure regardless
of time spent
Most CPT codes are complexity-based.
Time-based Codes
Time period is specified (e.g. 15 minutes)
Enter one code for each time period
Total volume=total time
Example: 2 units=30 minutes for a 15minute procedure
Few Audiology codes are time-based.
Time must be documented.
Audiology Services
CPT codes in the 92500-series
Technical and professional services
Do not require supervision by a physician
Performed by qualified audiologists
Must be ordered by a physician to be
billed.
General Purpose Codes
92506--evaluation of auditory processing
and/or aural rehabilitation status
92507--treatment of auditory processing
disorder (includes aural rehabilitation)
92508--group treatment
Often used (and abused) for hearing
evaluation and treatment, not elsewhere
classified
Audiology Treatment Codes
Audiologists cannot be reimbursed for
treatment services under Medicare
69200--foreign body removal
69210--cerumen management
97112--vestibular rehabilitation
Implant Services
Cochlear implant evaluation: Use
audiological assessment codes
Post-op analysis and fitting:
92601--Diagnostic analysis of CI, <7 yoa
92602--Subsequent programming, < 7 yoa
92603--Diagnostic analysis of CI, >7 yoa
92604--Subsequent programming, > 7 yoa
Billable as diagnostic services
CI Rehab (treatment)--92510 or 92507?
Vestibular Function Tests
With electrical recording
92541--spontaneous nystagmus test
92542--positional nystagmus test
92543--caloric vestibular test, each irrigation
92544--optokinetic nystagmus test
92545--oscillating tracking test (pursuit)
92546--sinusoidal vertical axis rotation test
Vestibular Function Tests
92547--use of vertical channel recording
Add-on code--usually limited to 92541
and 92542
No specific code for saccades (use
92700)
Vestibular Function Tests
Observation without electrical recording
No reimbursement value
92531--spontaneous nystagmus
92532--positional nystagmus
92533--caloric vestibular test
92534--optokinetic nystagmus
Audiological Assessment Codes
92551--screening test, air only
92552--pure tone audiometry, air only
92553--pure tone audiometry, air/bone
92555--SRT
92556--SRT and speech recognition
No code for PI/PB (use modifier 22)
Audiological Assessment Codes
92557--comprehensive audiometry
Bundled code (includes 92553 and 92556)
Do not code separately if all component
tests are performed
92559--group audiometric test
Middle-ear Function Tests
92567--acoustic immittance
(tympanometry)
92568--acoustic reflexes
92569--acoustic reflex decay
Site of Lesion Tests
92571--filtered speech test
92572--SSW
92576--SSI (ICM or CCM)
92563--tone decay test
92564--SISI
92565--pure tone Stenger test
92577--speech Stenger test
92589--central auditory function test
Less Commonly Used
Procedures
92573--Lombard test
92575--SAL
92562--loudness balance test (ABLB)
92560--Bekesy screening test
92561--Bekesy diagnostic test
Electrophysiological Tests
92584--electrocochleography
92586--auditory evoked potentials, screening
92585--auditory evoked potentials (ABR, MLR,
late potentials), diagnostic
92587--otoacoustic emissions, screening
92588--otoacoustic emissions, diagnostic
95920--intraoperative monitoring (added on to
primary procedure, e.g. 92585)
Hearing Aid Services
92590--HAE, monaural
92591--HAE, binaural
92592--hearing aid check, monaural
92593--hearing aid check, binaural
V5014--hearing aid repair
92594--electroacoustic test, monaural
92595--electroacoustic test, binaural
Hearing Aid Services
Programming--Use 92594 or 92595
Ear impression--V5275
Real-ear measurement--V5020
Otoscopy is part of examination and is not
coded separately. Video-otoscopy is
diagnostic and is coded as 92700.
Hearing Aid Services
97703 (each 15 min)--hearing aid orientation
92506--outcome measures
92507-aural rehabilitation (except implant)
Considered to be part of fitting*:
device ordering/handling (99002)
special supplies (99070)
patient education materials (99071)
group patient education (99078)
*not billable by audiologists
Balance Treatment
Audiologists treat vestibular disorders including
BPPV.
Peripheral vestibular rehab (canalith
repositioning) is within the audiologist’s scope of
practice. Code 97112.
PT/OT treats global balance problems (sensory
integration, proprioception).
Dynamic posturography (92548) is within the
PM&R scope of practice.
Global vestibular rehabilitation (97112).
Audiology: HCPCS Codes
V5008-hearing screening
V5010-V5298--hearing aid services
V5299--miscellaneous hearing service
L8614--cochlear implant device/system
L8619--speech processor replacement
L7510--repair of prosthetic device (not
hearing aid)
CPT Modifiers
Why Use Modifiers?
To indicate that a service was more or less
complex than typical
To indicate that a service was repeated or
discontinued
To add more information regarding the purpose
or anatomic site of the procedure
To help to eliminate the appearance of duplicate
billing
To help to eliminate the appearance of
unbundling (fragmentation).
CPT Modifiers
22--unusual procedural service
26--professional component (interpretation)
51--multiple procedures during same encounter
52--reduced service. Example: unilateral
procedure when bilateral is assumed.
CPT Modifiers
53--discontinued procedure
59--distinct procedural service on same day
76--repeat procedure by same provider
77--repeat procedure by other provider
99--multiple modifiers
Disease Coding
Structure of ICD-9-CM
3-, 4-, and 5-digit codes indicating levels
of specificity
Updated annually by working group
Diseases and injuries (001-999)
Factors influencing health status and
contact with health services (V-codes)
External causes of injury or poisoning (Ecodes)
Principles of Disease Coding
General rule: code to the highest degree
of medical certainty.
Use the most specific code possible.
Avoid NOS and NEC codes.
Non-physicians may code symptoms.
Choice of disease code has a great
affect on reimbursement.
NEC and NOS Codes
NEC--not elsewhere classified (xxx.x8)
NOS--not otherwise specified (xxx.x9)
NEC means that no appropriate code was
found in the tabular list based on the
information provided.
NOS means that the condition was not
adequately described by the provider.
NOS codes are usually not accepted
Outpatient Disease Coding
Condition that is chiefly responsible for the
patient’s visit is the primary diagnosis.
Primary diagnosis may be a disease, condition,
problem, symptom, injury, or reason for
encounter.
Secondary diagnoses may describe co-existing
conditions, symptoms, or reasons
Do not code conditions previously treated and
no longer exist.
Do not code “probable”, “suspected”,
“questionable”, or “rule out” diagnoses.
Primary and Secondary
Primary Diagnosis: disease, symptom,
condition or reason that is chiefly
responsible for the visit.
Secondary Diagnosis: other diagnoses
(e.g. relevant chronic conditions),
conditions that have impact on care, or
other conditions found after study.
Primary and Secondary
For treatment services:
Primary Diagnosis: reason that is chiefly
responsible for the visit.
Secondary Diagnosis: Condition treated and
other diagnoses (e.g. relevant chronic
conditions) or other conditions found after
study.
Primary and Secondary
For assessment services:
Primary Diagnosis: appropriate V-code to
indicate the reason for the exam
Secondary Diagnosis: any diagnoses,
conditions, or symptoms found after study
V-codes
Do not confuse ICD-9-CM V-codes with
HCPCS Level II V-codes.
ICD-9-CM codes are diseases, conditions,
symptoms, or reasons.
HCPCS Level II codes are procedures.
Audiology: ICD-9-CM V-codes
V19.2 (family history of hearing loss)
V19.3 (family history of ear disorder)
V41.2 (problems with hearing)
V53.2 (fitting/adjustment of hearing aid)
V65.2 (non-organic condition)
V65.43 (counseling for injury prevention)
V71.8 (observation for suspected condition)
V70.5 (exam for military personnel)
Normal Function
There is no ICD-9-CM code for normal
function. Normal function is not coded as
a disease.
V65.5 when there are no risk factors.
V71.89 when there is clinical reason to
suspect a problem.
Coding and Billing
Caveats
Every insurance carrier has its own rules.
Coding is not the same as billing.
Coding errors may lead to billing errors
Even accurate coding may lead to errors.
Not all billed codes are reimbursable.
Not all encounter codes are appropriate or
billable.
Billing errors, however innocent, may be
viewed insurance fraud.
What is Required to Assure
Accuracy (compliance)?
Billing codes must match documentation.
Documentation must support the scope and
level of service (complexity or time).
CPT codes must match diagnosis.
Services must be appropriate by provider type.
Services must be ordered by a physician (in
writing)
Reasons for Fraudulent Billing
Inadequate documentation
Improper coding
Services not provided
Fragmentation (unbundling)
Lack of medical necessity
Role of the Provider
Fully document clinical care
Provider is responsible documentation
Use accurate encounter forms
Encounter form is a tool. Documentation
is what is important.
Follow applicable coding and
documentation guidelines
Assist in verifying claims
What Can Be Done to Improve
Coding?
Coding handbooks and guidelines
Standard encounter forms (super bills)
Education
Good dialogue with coding and billing
officials
Electronic aids (templates, code filters,
prompts, taxonomies, e.g. CHCS-2)
Documentation
Principles of Documentation
Documentation must be:
Accurate--describes the care provided
Codable--supports CPT, ICD, DRG codes
Understandable--clear to reader
Timely--written at time patient was seen
Error free--stands alone as a legal document
Principles of Documentation
If ain’t documented, it weren’t done!
All care must be documented.
Anecdotal or historical events (patient not
present) should be documented.
All documentation must be dated and
signed.