Transcript Coding Basics

Coding Basics
Don’t make it harder than it has to be.
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History of ICD-9
 Originated in England during the 1700’s
 Called the “London Bills of Mortality”
 In 1930’s, morphed into the “International List of Causes of
Death”
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History of ICD-9
 1948, the World Health Organization (WHO)
developed the International Classification of
Disease (ICD)
 Goal was to create a tool to track morbidity and
mortality
 1977 the 9th edition was published, hence ICD9.
 Newer versions are ICD-9-CM (even more
clinical modifications)
ICD-10, that’s what I need to know!!
 ICD-10 transition is set for October 2014. The US is one of
the last countries to make the move.
 You will need to understand and know how to apply ICD9 well to make the transition easier.
 Because….ICD-10 is more complicated, six-digit, alphanumeric system.
 Specify laterality, new, follow-up, chronic, improved,
worsened, So much more detail!
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ICD-9 = Reimbursement
 Code what you see the patient for, and chart what you saw. In
other words:
 Do what is medically necessary, completely document what
you do and accurately code what you documented.
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To the Codes…

Steps to proper diagnostic coding:
1.
Code the chief reason or most acute condition as the primary
(#1) diagnosis.
2.
Use the alphabetical and tabular lists to get to the MOST
specific code possible.
Just like a homeopathic repertory…
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For example
 Patient comes in with an annoying wart, but you find they have
a a BP of 180/110 with a headache.
 Chief complaint PPR was a wart, but your coding is going to place
the hypertensive reading in the #1 slot, then the headache, then
the wart.
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Example, cont.
 You also need to get to the most specific ICD-9 code:
 If this patient has no prior hypertension then Blood, pressure, high,
incidental reading, without diagnosis of hypertension or 796.2 is
the code vs.
 Prior HTN would give you 401.9, for
HTN(uncontrolled)(fluctuating)(systemic)
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Example, cont.
 Then I would code the headache, which is a symptom of the
HTN:
 Headache, or Headache, vascular, both have code 784.0
 Last would be the wart: Wart, common 078.19
 Would I treat the wart today?
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Another example
 You have to get to the most specific code: this may only be 3
digits, 4 digits or the most specific 5 digits. (ICD-10 is 6 digits)
 Coryza = 460
 Cough = 786.2
 Abd pain, LUQ = 789.02 (789.0 gets you to Abd pain, the 2,
gives the LUQ)
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Let’s look at this a little deeper
 460=Acute nasopharyngitis [common cold]
 Coryza (acute), Nasal catarrh, acute
 Nasopharyngitis: NOS, acute, infective NOS
 Rhinitis: acute, infective
 EXCLUDES: nasopharyngitis, chronic (472.2)
 Pharyngitis: acute/NOS (462), chronic (472.1)
 Rhinitis: allergic (477.0-477.9), chr/NOS (472.0)
 Sore throat: acute/NOS (462), chronic (472.1)
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Let’s look at this a little deeper
 786.2 = Cough
 EXCLUDES cough:
 Psychogenic (306.1)
 Smokers’ (491.0)
 With hemorrhage (786.39)
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Let’s look at this a little deeper
789 Other symptoms involving the abdomen
or pelvis, EXCLUDES symptoms referable to
genital organs.
 789.0 Abdominal Pain
 0 unspecified site
5 periumbilic
 1 RUQ
6 epigastric
 2 LUQ
7 generalized
 3 RLQ
9 other specified site
 4 LLQ
multiple sites
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Next bit of detail…
 You now know you are going to code them from most
important (or acute) to least, and you’re going to code to the
highest specificity, now…
 You can only use a code once per visit (so bilateral issues,
need to be charted)
 You have four spaces, so use them, IF YOUR CHART NOTES
SUPPORT IT!!
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More Guidelines
 Signs and symptoms: Codes that describe
symptoms and signs, as opposed to diagnoses
are acceptable for reporting when a definitive
diagnosis has not been established (or
confirmed) by the provider.
 Headache (784.0) vs. Classical migraine without
mention of intractable migraine (346.01)
 Or, diarrhea, infectious, presumed (009.3) vs.
diarrhea, due to, Staphylococcus (008.41)
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More Guidelines
You cannot code items that are already
associated with a coded condition.
 Premenstrual syndrome (625.4), don’t add
cramps, abd pain, bloating…it’s implied in
primary code.
Do code items that are not part of the stated
condition.
 PMS, but they also have constipation and abd
pain not related to their cycle.
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More Guidelines
 Manifestations of one disease process, are
secondary to the primary condition.
 For example: Peripheral neuropathy and a leg
ulcer in a diabetic patient
1. DM w/ neuro manifestations, controlled (250.60)
2. Polyneuropathy (357.2)
3. Ulcer, skin, lower extremity, calf (707.12)
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More Guidelines
 If you have an acute exacerbation of a chronic condition and
you are seeing them for both today:
 The acute code is #1, followed by the chronic code
 Example: Acute maxillary sinusitis (461.0) in a person who
suffers from chronic sinustis (473.9)
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General vs. Specific
 Can be a red flag for insurance companies:
 Neck pain (723.1) every visit for the next two years says your
treatments aren’t very effective
 Low back pain (724.2) vs. Degeneration of lumbar intervetebral
disc (722.52), if you have a diagnosis, use it!!
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V codes
 Love ‘em, but you have to know how to use
them!
 “Supplementary Calssification of Factors
Influencing Health Status and Contact with
Health Services”
 Translation = exposures to illness, history of
illnesses, physicals, counseling, congenital
issues, screenings, outside factors in general
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V codes
 V70, most common v-code for annual exams and physicals
 V70.0 Routine general medical exam at a healthcare facility
 V70.3 other medical exam for admin
 Camp, school admission, sports, insurance, etc
 V70.5 Health exams of defined subpopulations (armed forces, preemployment, etc.)
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V code Guidelines
 If ANNUAL is to be applied to an individual’s
preventive insurance benefit (which is usually
pre-deductible), you MUST put it in the #1 slot
on the billing form.
 Other V codes are great, but be wary of putting
the following codes in the #1 spot if you want to
get paid…very few people have counseling or
preventive service benefits outside their annual
or possibly contraceptive care.
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Examples
 V72.32 Encounter for pap smear to confirm
recent NL smear following initial ABNL smear
 V72.40 Preg exam/test, preg unconfirmed
 V25.01 Prescription of OCP
 V25.04 Counseling in natural family planning to
avoid pregnancy
 MUST CHECK BENEFITS
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More Examples

V65.3 Dietary surveillance and counseling

V65.42 Counseling on substance use and abuse

V65.45 Counseling on other STDs

V69.2 High-risk Sexual behavior

V01.89 Exposure to parasitic disease

V75.1 Screening malaria

For Next week, have a copy of the Audit Tool printed out for reference during webinar!!!!!
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Putting it all Together for CPT
Mona Fahoum, ND
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CPT Layout
 Evaluation & Management
99201-99499
 Anesthesiology
00100-01999
 Surgery
10040-69979
 Radiology
70000-79999
 Pathology/Lab
80000-89399
 Medicine
90701-99199
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Evaluation & Management
(E/M)
 Codes 99201-99499
 Designed to describe the service provided by the practitioner.
 Both the ‘visit’ or evaluation, and the ‘treatment’ or
management of the condition.
 Also broken down by level of service and location (hospital vs.
office)
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Evaluation & Management
(E/M)
 Very good idea to read, read and re-read the
coding guidelines at beginning of this section,
pages 4-9.
 If you sign a contract with an insurance
company, you will be held to this system.
 If you don’t sign a contract with an insurance
company you will still be held to this system on
some level.
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CPT Guidelines
 Evaluation and Management Codes:
 Consist of new patient visits and return visits
 Take into account hpi, pfsh, ros, exam, time and
complexity.
 Components of each covered element during the
visit add up to the code you use for the encounter.
 CPT codes need to match ICD-9’s, which match
your charting
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E&M Codes
99201-99205, new patient medical visit
99211-99215, established patient visit
Also have Preventive visits in this category
 99382-99387 (New patient preventive)
 99392-99397 (established patient preventive)
-Make sure they have preventive benefits!!!
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E&M Codes
 Modifiers: add value to visit, we will cover later.
 Bundling: Insurances like to combine codes and pay only one.
 Peak flow during a visit is bundled into visit.
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CPT 99202
Office or other outpatient visit for the E/M of a
new patient, requiring these 3 components:
 An expanded problem focused history
 An expanded problem focused exam
 Straightfoward medical decision making
Counseling and/or COC is consistent with the
nature of the problem and the patient’s
needs.
Usually, the presenting problem(s) are of low
to moderate severity. Physician typically
spends 20 minutes face-to-face with patient.
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Versus a 99205
 Office or other outpatient visit for the E/M of a
new patient, requiring these 3 components:
 A comprehensive history
 A comprehensive exam
 Medical decision making of high complexity
 Counseling and/or COC is consistent with the
nature of the problem and the patient’s needs.
 Usually, the presenting problem(s) are of
moderate to high severity. Physician typically
spends 60 minutes face-to-face with patient.
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CPT 99213
 Office or other outpatient visit for the E/M of an
established patient, requiring 2 of these 3
components:
 An expanded problem focused history
 An expanded problem focused exam
 Medical decision making of low complexity
 Counseling and/or COC is consistent with the
nature of the problem and the patient’s needs.
 Usually, the presenting problem(s) are of low to
moderate severity. Physician typically spends 15
minutes face-to-face with patient.
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Versus 99214
 Office or other outpatient visit for the E/M of an
established patient, requiring 2 of these 3
components:
 An detailed history
 An detailed exam
 medical decision making of moderate complexity
 Counseling and/or COC is consistent with the
nature of the problem and the patient’s needs.
 Usually, the presenting problem(s) are of
moderate to high severity. Physician typically
spends 25 minutes face-to-face with patient.
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So what next?
 We have to figure out what problem-focused
means as compared to expanded, detailed and
comprehensive.
 We have to figure out what low-moderate and
high severity look like.
 We have to figure out what low-moderate and
high complexity mean.
 Grab your audit tool and fasten your seatbelt.
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Subjective/Objective Section
 Did you do HPI, how completely?
 ROS, how many systems?
 PFSH, how many areas?
 PE, Count up your systems and areas
Chart what you do, pertinent positives, check off the negatives.
GET VITALS!
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Systems or Body Areas??
 There are two ways to get your ‘points’ for
physical exam.
1.
Document at least two bullets from the
specified number of systems, or
2.
Document all bullets from a given area, plus at
least one bullet from other pertinent
areas/systems
Look at the chart notes from last week as an
example, each check box is a ‘bullet’ from
the official E/M guidelines.
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Official Guidelines
 Link to the official E/M guidelines, most recent version from
1997.
 http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf
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So, the audit tool
1.
HPI, ROS and PFSH
2.
Exam
3.
MDM
For HPI and Exam let’s look at the differences between problem
focused, detailed and comprehensive.
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HPI/PE are relatively straight foward, but then
we get to MDM. . .
 The rest of this audit tool is our mechanism to working out our
level of Medical Decision Making
 More Precisely the Complexity and Severity of the case.
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Number of Diagnoses
If you have four, use four ICD-9s.
Remember, it may be better to use only a couple and thoroughly
work them up.
Let’s look at the table.
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Amount or Complexity of Data
 Records to review, consulting with another
practitioner, labs, etc.
 Another piece is Coordination of Care with other
providers
 The trick is you need to write this in your chart
note, we often do it, but don’t document it.
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Table of Complexity
 Go to audit tool for descriptions of:
 Minimal
 Low
 Moderate
 High
 This is all very grey, not black/white
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Final Result of Complexity
 Take points from Diagnoses section of tool and
plug into line 1,
 Plug final level of risk from Table of Complexity
into line 2,
 Put points from Data section into line 3, and we
get to,
 Decide final complexity based on result from
each column.
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Final Result of Complexity
Final Medical Decision Making will be:
 The column where you have 2 of the 3 items, or
 If one in each column, take the middle value
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Putting it all together…
For a new patient: must have elements from
all 3 areas, HPI, PE and MDM
 Decision will be based on each of these elements
and follows the same principle as the ‘Final
Result of Complexity’ table.
For an established patient: only need to
meet 2 of the 3: HPI, PE and MDM, so a little
easier to get higher level, but beware…
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And to help get you there:
 Can use additional factors:
 Nature of presenting problem (not as important for us NDs)
 Counseling
 Coordination of Care
 Time
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Nature of Presenting Problem
 Nature of Presenting Problem:
 Minimal: doesn’t require a physician to be present (ie. BP
check)
 Self-limited: problem runs a definite and prescribed course
with no long-term sequelae
 Low severity: risk of morbidity without Tx is low and little to
no risk of morbidity/mortality
 Moderate severity: risk without Tx is moderate and there is
a moderate risk of morbidity/mortality w/o Tx. May also
have an uncertain prognosis or increased probability of
prolonged functional impairment.
 High severity: Risk of morbidity w/o Tx is high, risk of
mortality is high or there is a high probability of prolonged
functional impairment.
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Counseling and COC
Time spent in discussion with the patient,
family or another physician concerning:
 Diagnostic results, impressions or recommended
studies
 Prognosis
 Risks and benefits of treatment options
 Instructions for management/follow-up
 Importance of compliance with chosen Tx
 Risk factor reduction
 Patient and family education
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Time
 THIS IS FACE-TO-FACE TIME ONLY
 If more than 50% of visit is spent in counseling then you may
code at one level higher or based on time.
 Great if you’re in between levels, or need help justifying
complexity.
 A lot of controversy over this issue. It’s totally fine as long as
you have met 2 of the 3 elements above in your charting!!
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To the codes…
NEW Patients: Have not been seen by you
or anyone in your office of the same
specialty for more than three years.
 99201-99205
 10, 20, 30, 45 and 60 minutes typically
Established patients: Everyone else
 99211-99215
 5,10, 15, 25, and 40 minutes typically
BUT what did we say about time????
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Consultations
 99241-99245
 Won’t be paid…
 Medicare took out this year, so others will follow
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Preventive medicine services
Includes a ‘check-in’ on chronic diseases,
but if a new or acute condition or
exacerbation is reported can use an E/M
code in addition with modifier -25
(significant/separate E/M)
Broken down by ages
 New: 99381-99387
 Established: 99391-99397
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Prolonged service codes
 Overused in our profession, and a flag for insurance
companies.
 Very legitimate codes, when used properly.
 Now that we can use time for billing when >50% is in
counseling, you really don’t need these so much if you
have good time management skills.
 If you do use them, you have to document the start and
stop times of care in your notes.
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Prolonged service codes
 The definition of these codes is very clear that it is for face-to-face
time spent ‘beyond the usual service’.
 Therefore, if you spend 90 minutes with every patient, this is your
usual service, not a special circumstance.
 If the visit takes longer d/t Hx, exam or counseling/coc, then use a
higher level E/M code, but
 If it is taking longer d/t language barrier, multiple family members,
hard of hearing or other prolonged service (ie asthma attack) then
these are acceptable codes.
 Approximately 5-10% of billings out of a given office.
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Prolonged Service codes
 99354 for the first extra 60 minutes of time spent with patient.
 99355 for each additional 30 minutes spent w/ patient.
 Get added on top of your E/M code.
 For example, if someone comes in with an asthma attack, but is well
handled, just needs to be observed, then you might do a 99214 with a
99354. Same thing if Grandma comes in and it takes a long time to
describe the treatment to her, it might be a 99213 with a 99354.
 But, if it is a regular office visit and you just spend a lot of time
counseling, so this is purely based off time, then you have to meet the
requirements of a 99215 time-wise before you add the prolonged
service code on. Basically, it has to go at least 90 minutes, with 60 of
that in counseling alone.
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Coding Case #1
 65-year-old white male who presents to clinic for refill on
furosemide, which he takes for treatment of CHF. The patient
states that he ran out of his medication three days ago and is
concerned that he may be "headed for trouble." The patient
watches his weight carefully and noted a 5-lb. weight gain over
the last one week.
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CHF, cont.
 The patient denies any chest pain or pressure, shortness of
breath, dyspnea on exertion or change in the condition of twopillow orthopnea. He denies any headache, dizziness, nausea
or vomiting. He denies any lower-extremity swelling.
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CHF, cont.
 Medications: furosemide 60 mg qd, potassium
supplement 10 mEq qd, digoxin 0.125 mg qd,
captopril 12.5 mg qd, aspirin 325 mg qd.
 No known allergies.
 Past medical history: CAD, CHF.
 Social history: No tobacco or alcohol use.
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CHF, cont.
 Vital signs: BP 140/80 sitting, 138/85 standing; P80; R 14; T 98.7; Wt. 185#
(baseline 180#)
 General: Well-developed, well-nourished white male, pleasant and cooperative, in
no acute distress. Mood is somewhat anxious.
 HEENT: Conjunctivae: nonicteric; oropharynx: moist mucous membranes.
 Neck: No JVD, no bruits.
 Heart: Regular rate without murmur or S3.
 Lungs: Breathing unlabored; clear to auscultation bilaterally, no wheezes or rales
noted.
 Abdomen: Nontender, nondistended, no hepatosplenomegaly.
 Extremities: No cyanosis, clubbing or edema.
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CHF, cont.
 Labs: BUN 25; creatinine 1.0; sodium 138; potassium 4.2;
chloride 101; bicarb 24.
 Assesment: CHF-stable
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CHF, cont.
Prescription for furosemide 60 mg qd,
dispense 30 with two refills was written.
Patient was encouraged to continue
monitoring weight daily and to follow sodium
restrictions as previously instructed. Patient
was instructed to continue digoxin,
potassium supplementation, captopril,
aspirin; no refills needed at this time. Return
to clinic for follow-up in one month, sooner if
symptoms persist.
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CHF, final
Remember, three key components:
 History, ROS/Exam, Medical decision
 So:
 History is 99213
 ROS/Exam is 99214
 Medical decision is 99212
 For ROCs:
Final Code is 99213, Highest code that 2 of the 3
components have in common
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Case #2, Established patient
CC: F/U HTN
INTERVAL HISTORY: HTN is well controlled, patient is compliant
with meds and working on diet/exercise. Hyerlipidemia is also
stable per recent labs. Review of systems is negative for chest
pain, shortness of breath, DOE, vision change, HA or edema in
lower extremity.
Exam shows a BP 126/78, HR 76, RR 20. Patient appears well.
Heart RRR, LUCTA, No edema in limbs b/l. Labs show a
creatinine of 0.9, electrolytes are normal. LDL is 75.
IMPRESSION: Stable HTN and hyperlipidemia.
PLAN: No changes needed. Continue current meds. ROC in six
months.
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Case #2, htn/hyperlip
 HPI: 99213
 Exam: 99213
 MDM: 99212
 2 out of three, says final code is 99213
 The most used code out there…
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25 Y.O. Female FOC

Subjective

CC1: Last few years, constant diarrhea, sharp pain, stool urgency, no accidents.
No blood or mucus. Can get 'wiped out' after diarrhea. N, lots eructations, no
reflux/ No V. Stomach pain can be with/without food, with/without immediate
diarrhea (up to 2 hours of pain). Pain is low abd, after stool is all out (up to 3 BMs in
an hour) then pain subsides. 3BMs QD, up to 5BM. No constipation. No gas.

No problems prior, could eat anything, spicy, etc. Now no spicy food, tried
minimizing dairy, gf, but not completely so no symptom change.

H/O planned parenthood: Last pap 2010, wnl, No STD hx, G1P1A0. Menses reg,
bleed 4-5 days, just stopped OCPs, cramping, but major mood swings.

H/O anemia, “everytime checked”. Last bloodwork at gastro in Edmonds, few
months ago. Gluc wnl, all nl ppr.

Not on any medications or supplements currently.
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25y.o. female, cont.

DIET HISTORY and SHx:
B: eggs, tortilla, sour crm, tomato, onion, bacon. Hates Coffee, can't have straight milk, spicy
foods
S: Pepsi and a red bull (can't make it through day without caffeine)
L: Pho or sandwich
D: soup/salad or salmon, potatoe, veggie

EtOH: couple drinks a week (wine), Water: 3-4 glasses

NS, Fish 1/wk, lots of meat (beef, pork, cxn), not a big fruit person.
Has to eat every four hours, or feels nauseous/lightheaded
Falls asleep easily, getting 8 hours, hard to wake. Tosses all night, wake to urinate 2+/night since
daughter.
Worrier by nature. Daughter, Finances, etc. Hard to let boyfirend support her while thinking
about going back to school. Also worries about where next bathroom is.

PMHx: cesarean with daughter 2005, No other surgeries, No other hosp, no major illnesses.
Healthy kid, may have adenoids out as kid (unsure), had tubes in ears.

PFHx: Sister has Crohns (24y.o., started at 15), no one else in family IBD. PGM colon cx.
MGF MI at 49 y.o. Mom-HTN, Dad-hyperlip, but healthy. No DM.
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25y.o. Female, cont.
ROS: General: No weight change, generally healthy, no change in strength, unable
to exercise d/t diarrhea/fatigue. Head: No headaches, no vertigo, no injury. Eyes:
Normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: No change in
hearing, no tinnitus, no bleeding, no vertigo. Nose: No epistaxis, no coryza, no
obstruction, no discharge. Chest: No dyspnea, no wheezing, no hemoptysis, no
cough. Heart: No chest pains, no palpitations, no syncope, no orthopnea. GU: No
urinary urgency, no dysuria, no change in nature of urine. Gyn: No change in
menses, no dysmenorrheal, no vaginal discharge, no pelvic pain. Musculoskeletal:
No pain in muscles or joints, no limitation of range of motion, no paresthesias or
numbness. Psychiatric: No depressive symptoms, no changes in sleep habits, no
changes in thought content.
Objective: BP 112/70, HR 72, RR 12, Wt 135, Ht 54 inches

General: Normotensive, in no acute distress. Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM's full, conjunctivae pale. Nose: Mucosa normal, no obstruction.
Neck: Supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales,
no rhonchi, no wheezes. Heart: RR, no murmurs, no rubs, no gallops. Abdomen:
Soft, no tenderness, no masses, BS normal. No organomegaly. Skin: Normal, no
rashes, no lesions noted, capillary refill slow. Extremities: Cold, well perfused, no
edema.
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25y.o. female, cont.
 Assessment
1. Diarrhea 2. Abdominal Pain, unspec. 3. Nausea 4. Anemia
 Plan:
Spent 60 minutes with patients, 30 minutes in counseling
around need to r/o Crohns. Pt unable to pay for colonoscopy as
recommended by Gastro, so we decided on ASCA. I suspect that
this is dietary related, we discussed high intake of sugar, possible
dysbiosis, lack of dietary fiber and food intolerance. Pt. has strong
desire for food allergy testing, and is unable to adhere to full
Elimination diet.
1. Drew for ASCA, ferrritin, CBC, TSH, food allergies today.
2. Requested last labs from gastro at Krueger Clinic in Edmonds.
3. Increase water, veggies. Add an emergen-c to morning water.
4. Cut down on soda/redbull or at least chase with water. Consider tea
instead.
5. Improve sleep. Melatonin 3mg qhs.
6. Hemaplex, 1 po qd
7. F/U 2 weeks.
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Billing for this FOC
 Component 1/History:
HPI: Extensive (>4 elements)
ROS: Complete (>10 systems)
PFSH: Complete (>2 areas)
= 99204 or 99205
 Component 2/Physical Exam:
Comprehensive (general multi-system exam)
= 99204 or 99205
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Billing for this FOC
 Component 3/ Medical Decision Making:
Decision making: moderate complexity (204)
# Dx/management options: multiple (204)
Amt/complexity of data: limited (203)
Risk/morbity/mortality: moderate
(203)
Best two of three:
HPI = 204 or 205
PE = 204 or 205
MDM = 203 or 204
Final CPT chosen is 99204, some may choose to do 99205, due to
time and counseling, and could probably justify, but in reality, her
risk and my level of intervention is not invasive or overly complex.
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25 y.o. follow-up visit
 Subjective
 Patient returns to follow-up for abd pain and diarrhea. She
started iron (hemaplex) and had more energy, but it constipated
her a bit so she discontinued. Slowing down her BMs would have
been a good thing, except with the pain, the only relief is the BM.
 Since stopping the iron she has noticed good improvement just
by implementing more veggies and lowering her sugar intake.
She is still using energy drinks but found one with half the amount
of sugar as red bull, she is also limiting other refined carbs. She
has also done better with increasing her water to 30-40 oz.
 BMs are now only two per day, less pain, but still very loose with
some (but less) sense of urgency.
 We review her labs, CBC, ferritin and ASCA testing all WNL. Food
Allergies all negative.
 No new medications
 No Change PFSH
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25 y.o. follow-up

ROS:

General: No weight change, generally healthy, no change in strength or exercise
tolerance.

Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Heart: No chest
pains, no palpitations, no syncope, no orthopnea. Abdomen: No change in
appetite, no dysphagia, no emesis, no melena. Psychiatric: No depressive
symptoms, no changes in sleep habits, no changes in thought content.

Objective: BP 110/68, HR 68, Ht 54 inches, Wt 135

General: Normotensive, in no acute distress.

Head: Normocephalic, no lesions.

Eyes: PERRLA, EOM's full, conjunctivae clear.

Abdomen: Soft, no tenderness, no masses, BS normal.

Extremities: Warm, well perfused, no edema.
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25y.o. follow-up
 Assessment: Diarrhea, generalized Abd pain
 Given negative testing for Crohn's at this point and negative food allergies, we are going to
treat as inadequate fiber, suspected lactose intolerance and dysbiosis.
 Plan:
 Spent 30 minutes face to face with patient, 25 in counseling regarding labs, IgE vs. IgG
allergy, lactose intolerance and dysbiosis. Given that she is already vastly improved with
only one week of reducing sugars, she will continue that route dietarily, along with
eliminating dairy for one month. Then we will test goat and sheep products, followed by
cow.
 1. Oregano oil 1 cap BID for 30D
 2. HLC 2 caps QD x 30D
 3. Continue to work to get the energy drinks switched out completely, or at least to only
those sweetened with cane sugar.
 4. Continue to increase water intake, veggie intake. Fiber handout given, with goal to get
to 30g daily.
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Billing for this ROC
 Component 1/History:
HPI: brief (1-3 elements)
ROS: ext (2-9 systems)
PFSH: pertinent (1 area)
= 99213 or 214
 Component 2/Physical Exam:
Limited for affected area + other related areas
= 99213
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Billing for this ROC
 Component 3/ Medical Decision Making:
Decision making: low complexity (213)
# Dx/management options: limited (213)
Amt/complexity of data: multiple (214)
Risk/morbity/mortality: low
(213)
Best two of three:
HPI = 213 or 214
PE = 213
MDM = 213
Final CPT chosen is 99214, from the point system it is a 99213, but
with the majority (>50%) in counseling, plus the time I spent (30
minutes) I get to bump it up one level.
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Procedure and Physical Medicine
Coding
Mona Fahoum,
ND
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Onward…
 Office Management tips
 Procedure codes (lavages, I&D’s, etc)
 Physical Medicine Coding
 Modifiers
 Software review
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Billing Ease…Relatively
 Stay on top of charting
 Use superbill or fee slip, always create a paper trail
 No matter how electronic your office is, you need a PAPER TRAIL.
 Write legibly.
 Sign and date EVERYTHING.
 Document, document, document.
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Common Errors
 Wrong ID/group numbers
 Wrong ‘insured’ information
 CPT/ICD-9’s don’t match
 Multiple visits on same day
 Missing Diagnosis pointers
 Always double-check before sending to catch the silly
errors that hinder payment.
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Tip of the Day
 Know your services, Know what is billable…
Just because there is a code, doesn’t mean you can use it, and just
because it got paid, doesn’t mean it’s right.
Unfair, but true.
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Home Visits and Telephone Calls
 Could try to bill, but won’t pay…
 New patient: 99341-99345
 Est. patient: 99347-99350
 Payable, but probably not on our fee schedule,
reserved for disabled, nursing care, hospice mostly
 Telephone calls: 99371-99373
 Build these as cash services, have patients sign
a non-covered service agreement.
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Bundling
Term insurances use to mean that two services (or
CPTs) are related and therefore, paid as one.
Best example is with a wound repair. Suture
removal a week later is part of placing the sutures.
Another, Post-IUD placement, 30-day follow-up for
string check is part of original insertion bill.
Another, doing a peak flow will get bundled into the
E/M, it’s part of evaluating asthma.
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Bundling
Less fair in physical medicine:
 Manual therapy is bundled into your Manipulation code
since it is assumed that some manual therapy is a part of
the manipulation.
 Not true, but that’s the way it is…
 Also, billing for hot packs will get bundled into the other
service you’re providing, will not get paid separately by
medical insurance.
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Procedure Codes
 Generally pay well. Assumed that you have done evaluation
appropriate to performing the procedure, therefore do not get an E/M
for that visit in addition.
 Unless… you see the person for two or more, ‘Significant & Separately
identifiable Services. (modifier -25)
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Procedure Codes
Most commonly used codes:
 69210, Cerumen removal
 10060, I & D of an abscess
 11200, Skin tag removal (up to 15)
 17110, Cryosurgery
 90760, IV-hydration
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Procedure Codes
 All come with a description of the procedure so you
need to read these.
 For example:
 10060 is ‘incision and drainage of abscess
(carbuncle, suppurative hidradenitis, cut/subcu
abscess, cyst, furuncle, or paronchyia), simple or
single
 If multiple then it changes to 10061, and if you didn’t
actually use a scalpel and just did puncture aspiration
of an abscess, hematoma, bulla or cyst its 10160.
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Procedure Codes
Remember that many of these will get bundled into
the E/M you are billing:
Peak flow, 94200 is a part of the management of
asthma.
Anoscopy, 46600 is a part of evaluating
hemorrhoids.
Sometimes have to do a little trial and error.
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Laboratory Codes
 Can only be done if completed in the office.
 In Washington, must have a CLIA certificate to do in-office tests.
 No modifiers needed, just go on another line on the CMS from.
 Reimburse poorly, so use your time wisely.
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Laboratory Codes
 36415, Venipuncture
 87880, Rapid Strep
 86580, PPD insertion (includes read)
 81002, UA dipstick
 84703, Urine HcG
 87210, Wet mount for infectious agents
 87220, KOH prep (skin/hair/nails for fungi or ova/mites)
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Laboratory Codes
 May not pay much, but missed cash every time you don’t bill for what
you do…
 Anyone know how much a box of Rapid streps or a bottle of urine HcG
tests are?
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Physical Medicine Codes
 Hot topic and there is a lot of controversy and different opinions here.
 I take a very literal approach, and encourage you to read these sections
of the CPT book as you start using these codes.
 Don’t just do what others do--that’s a very good way to do things
erroneously.
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Physical Medicine Codes
 Codes 97010-97546, modalities and therapeutic procedures.
 Codes 98925-98929, Osteopathic manipulation codes.
 Not 98940-98943, chiropractic codes.
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Physical Medicine Codes
 97010, hot/cold packs, rarely paid because required no supervision by
practitioner.
 97024, diathermy, also rarely paid, but can do both of these while doing
something that does pay you.
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Physical Medicine Codes
 Constant attendance codes, 97032-97039 and therapeutic procedures
97110-97140 are paid in 15 minute increments.
 Iontophoresis, ultrasound, massage, neuromuscular reeducation,
therapeutic exercise, manual therapy, etc.
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Physical Medicine Codes
 REQUIRE face-to-face contact by provider, ie cannot have a staff
person do it for you.
 When billing need to be aware of time, there is some leaway, if you do
50 minutes you get to bill for 4 units (60 minutes)
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Physical Medicine Codes
Most common codes:
 97110: Therapeutic exercise to 1 or more areas,
each 15 minutes; exercises to develop strength
and endurance, range of motion and flexibility.
 97124: massage, including effleurage, petrissage
and/or tapotement.
 97140: manual therapy techniques
(mobilization/manipulation, manual lymphatic
drainage, manual traction), 1 or more regions,
each 15 minutes.
 97112: NM re-edu of mvmt, balance, coordination,
posture and proprioception for sitting/standing
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Physical Medicine Codes
 OMT codes are billed not on time, but on areas manipulated:
 1-2, 3-4, 5-6, 7-8, 9-10 areas, each corresponds to a CPT code
 Areas are: head, cervical, thoracic, lumbar, sacral, pelvic, lower
extremities, upper extremities, rib cage, abdomen/viscera
 Code set: 98925-98929
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Physical Medicine Codes
 Here’s the controversy:
 OMT codes include ‘preservice and postservice work associated with
the procedure’. But, can use E/M with them if for a significant and
separately identifiable service. (have to use a modifier to link them).
 What does this mean?
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OMT
 Only use an E/M codes in conjunction with these codes if you
are assessing a new problem, re-assessing an existing
complaint periodically through treatment or are also seeing them
for a ‘medical’ concern in addition to providing a physical
medicine service on the same day (use -25 on E/M or -51 if
another procedure).
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Semantics
Assessment is a part of any OMT, you don’t do
manipulation without evaluation.
If you are doing a re-vamp of your plan, then could
use a brief E/M with your treatment, chart well.
If you are doing manual therapy with an OMT will
get bundled…manipulation is part of definition of
manual therapy, so double-dipping.
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Semantics
 However, NMT and Therapeutic exercise and massage do not have a
manipulation component so you can bill the use of stretching/MES/etc.
with OMT.
 Have to understand definitions of these codes and/or, give a little
manual therapy away…
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Modifiers
 Because you can only see a patient once per day, if you do multiple
services then you have to ‘link’ them.
 In other words, let the insurance company know that they need to
consider a special circumstance in this visit and pay you more.
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Modifiers
 For example, in phys med:
 Patient comes in for a treatment, but also follow-up on HTN. You take a
quick history, med review, vitals, cardio exam, then do 45-minutes of
Therapeutic exercise.
 What CPT’s do we need?
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 Significant, separately identifiable evaluation and management service
by the same physician on the same day of the procedure or other
service.
Modifier -25
 Effectively links the two services together, provided that you have
charting on both pieces.
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Modifier -25
Can use with OMT or phys med codes as in
example, or if you have to re-assess the same
complaint (ie neck pain, or sciatica)
Can use if someone comes in with a sinus
infection on the same day as their physical
Can use if you see someone for HTN and do a
cerumen removal on the same day.
ALWAYS, gets attached to the E/M code.
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Modifier -25
 Can use with the same ICD-9 codes.
 For example, a patient comes in with a headache, you take a history do
an exam and end up treating them with a cervical adjustment.
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Modifier -51
This modifier is used to show multiple
procedures: Use it when you perform
multiple procedures, other than E&M
services, in the same session. For
example, an ear lavage and a liquid
nitrogen treatment on the same
day/same visit. USE ON SECONDARY
CODE, IT WILL OFTEN ONLY PAY AT
50%.