Transcript CPT Coding and Why You Care

CPT Coding
and Why You
Care
Ted A. Bonebrake, M.D.
CPT Coding
 Current
Procedural Terminology
 System of coding medical encounters for
billing purposes in the US
 First published by AMA in 1966
 Updated annually on January 1
CPT Coding
E
& M Codes (Evaluation and
Management)
 Procedural Codes
 Pathology, Laboratory, Radiology
CPT Coding
Why do we care?
1. Correct coding results in correct
reimbursement
2. Coding errors can result in claim
rejection, rebilling and delayed
reimbursement
3. Providers are responsible for errors
4. Incorrect coding may result in charges
and fines
Reimbursement
 Most
family
physicians today are
employees of a clinic
or hospital system
 Part or all of physician
compensation is
based on production.
Reimbursement
 Salaries
and/or bonuses are typically
based on production which is determined
one of two ways:


Gross receipts minus overhead
RVU’s (Relative value units)
 Either
method is ultimately determined by
the CPT codes that a provider bills for.
Incorrect Coding
 False
Claims Act 1986
 HIPAA 1996
 The Office of Inspector General (OIG) and
the Department of Justice enforce
federal, state, and local laws to control
healthcare fraud and abuse
 They conduct investigations and audits
pertaining to the delivery of and payment
for healthcare services.
Incorrect Coding
 In
egregious cases, a
doctor can be fined,
excluded from
Medicare and
Medicaid, lose their
medical license, and
even do jail time.
 More commonly, the
government imposes
financial penalties.
Incorrect Coding
 The
civil monetary penalty for healthcare
fraud has been increased from $2000 to
$10,000 for each item or service for which
fraudulent payment has been received.
 The monetary assessment has been
increased from not more than twice the
amount to not more than three times the
amount of the overpayment.
Incorrect Coding
 Two
practices have been added to the
list of fraudulent activities for which civil
monetary penalties may be assessed:
1. Engaging in a pattern of presenting claims
based on a code that the person knows or
should know will result in greater payments
than appropriate.
2. Submitting a claim or claims that the
person knows or should know is for a medical
item or service that is not medically
necessary.
Audits and Investigations
What will trigger an
audit or investigation?
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A pattern of
“upcoding”
Whistle blowers
E & M codes that are
consistently different
than average
distributions for your
specialty
Within a group setting,
inconsistent coding
among partners.
Audits and Investigations
What will trigger an audit or
investigation?
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Excessive use of a code.
Coding level 5 services and not preventive
medicine codes for annual physicals.
Use of symbols or shorthand
Lack of specificity about what you are
reviewing. (Review of systems as
unremarkable is insufficient)
Frequent coding based on “time”
CPT codes national average
60.00%
50.00%
40.00%
30.00%
CPT codes
national average
20.00%
10.00%
0.00%
9921199212992139921499215
Procedural Coding
 There
is a code for
every procedure
that physicians
perform
 Each code dictates
the price for that
service that will be
charged by the
physician
Procedural Coding
 Each
code is a five-digit number, which
identifies the procedure or service
 Health care entities (hospitals, clinics,
individual providers) attach a price to
each code
 Actual reimbursement will vary
depending on what insurance companies
or government payers will allow
Procedural Coding
Organization of codes
 Anesthesia
00100-01999; 99100-99140
 Surgery
10021-69990
 Radiology
70010-79999
 Pathology & Lab
80048-89356
 Medicine
90281-99199; 99500-99602
Procedural Coding
Add-on codes
 Additional
procedures that are commonly
done in addition to the primary
procedure
 Identified by terms like “each additional”
 Performed by same physician
 Cannot be reported separately
Procedural Coding
Modifiers
 Additional
two-digit code that is added to
the primary CPT code
 Format: 11300-59
 Some modifiers are attached to E & M
codes; others to procedural codes
Procedural Coding
Modifiers
 Both
a professional and technical
component
 More than one physician and/or location
 Only part of a service was performed
 An adjunctive service was performed
 A bilateral procedure was performed
 Service or procedure performed more
than once
Procedural Coding
Global Procedure Codes
 Most
procedure codes are “global”, i.e.
they include ALL care related to that
particular procedure
 May or may not include initial encounter
 For example, fracture care includes initial
evaluation, treatment (splint or cast),
follow up, and treatment of
complications, if done by same provider
E & M Coding
 Evaluation
and Management
 Billing for an E/M service requires the
selection of a Current Procedural
Terminology (CPT) code that best
represents:
❖ Patient type;
❖ Setting of service; and
❖ Level of E/M service performed.
E & M Coding
 The
“level” of the code is then
determined by three components:
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Patient History
Physical Exam
Medical Decision Making
 For
a new patient, all 3 components are
used. The lowest “level” determines the
code.
 For established patients, only 2 out of 3
are needed.
E & M Coding
Patient Type
 For
purposes of billing for E/M services,
patients are identified as either new or
established:

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New patient -- has not received any
professional services from the
physician/non-physician practitioner (NPP)
or another physician (of the same specialty)
who belongs to the same group practice in
the past three years.
Established patient -- has received
professional services as noted above in the
past three years.
E & M Coding
Patient Type
 “Any
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
professional services” includes:
Emergency department visit
Treatment as an inpatient (including
newborns)
Nursing home visit
Outpatient visit at any location
E & M Coding
Patient Type
 Example
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 Is
#1
Joe comes in c/o cough. He has never
been seen at FPC.
When reviewing his chart, you see that he
had a knee replacement in 2012 at Allen.
Dr. Johnston was the attending physician.
Family Practice was consulted for medical
management of his hypertension.
Joe a new or established patient for
E & M Coding purposes?
E & M Coding
Patient Type
 Example
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 Is
#2
Holly comes to the clinic for follow up of
hypertension, diabetes and CHF.
She moved away in July 2011, but just
moved back to Waterloo.
Her FPC chart contains a complete history,
and her last office visit was 12/01/10.
You note that her medications were refilled
by phone on 7/01/11.
Holly a new or established patient for
E & M coding purposes?
E & M Coding
Patient Type
 Example



 Is
#3
While you are on team, you admit Alfred for
CHF. Dr. Kettman is his PCP.
The following year, Alfred changes
insurance carriers, and can no longer see
Dr. Kettman.
He remembers the excellent care you gave
him in the hospital, and comes to FPC to
see you for his CHF.
Alfred a new or established patient for
E & M coding purposes?
E & M Coding
Setting of Service
 E/M
services are categorized into different
settings depending on where the service
is furnished. Examples of settings include:
❖ Office or other outpatient setting
❖ Hospital inpatient
❖ Emergency department
❖ Nursing facility
❖ Home
E & M Coding
Setting of Service
 In
each setting, there different types of
services which may be billed.
 OFFICE
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Office visit
Office consultation (new or est.)
Preventive medicine services
 Nursing



Facility
Initial nursing facility care (new or est.)
Subsequent nursing facility care
Nursing facility discharge
E & M Coding
Setting of Service
 Hospital
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Initial hospital care (new or est.)
Subsequent hospital care
Observation (admit/discharge same day)
Hospital discharge
Inpatient consultation
 Emergency
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Department
Emergency department visit (new or est.)
Physician direction of EMS care
E & M Coding
Setting of Service
 Critical
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Care
May be billed in hospital or ED setting
Critical care E/M (first 30-74 minutes)
Critical care (each additional 30 minutes)
 Domiciliary
or Rest Home Services
 Home Services
E & M Coding
Setting of Service
 Prolonged
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
Services
With direct patient contact
Without direct patient contact
 Anticoagulant
Management
 Medical Team Conferences
 Care Plan Oversight Serices
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Home health agency
Hospice
Nursing facility
E & M Coding
Level of Service Provided
 In
general, the more complex the visit, the
higher the level of code the physician or
NPP may bill within the appropriate
category.
 In order to bill any code, the services
furnished must meet the definition of the
code.
 It is the provider’s responsibility to ensure
that the codes selected reflect the
services furnished.
E & M Coding
Level of Service Provided
 There
are three key components when
selecting the appropriate level of E/M
service provided:



Patient History
Physical Examination
Medical Decision Making
 The
criteria for each component varies
depending on the setting and type of
service.
E & M Coding
Level of Service Provided
 Visits
that consist predominately of
counseling and/or coordination of care
are an exception to this rule.
 For these visits, time is the key or
controlling factor to qualify for a particular
level of E/M services.
E & M Coding
Level of Service Provided
E&M
CODE
HISTORY
EXAM
MDM
99201
Problem
Focused
Problem
Focused
Straightforward
99202
Expanded PF
Expanded PF
Straightforward
99203
Detailed
Detailed
Low
Complexity
99204
Comprehensive
Comprehensive
Moderate
Complexity
99205
Comprehensive
Comprehensive
High
Complexity
E & M Coding
Level of Service Provided
E&M
CODE
HISTORY
EXAM
MDM
99211
Nurse Visit
----
----
99212
Problem
Focused
Problem
Focused
Straightforward
99213
Expanded PF
Expanded PF
Low
Complexity
99214
Detailed
Detailed
Moderate
Complexity
99215
Comprehensive
Comprehensive
High
Complexity
E & M Coding
Level of Service Provided
Patient History Definitions
 Problem
Focused: CC, brief HPI
 Expanded PF: CC, brief HPI, pertinent ROS
 Detailed: CC, extended HPI, extended
ROS, pertinent PMH, FH and/or SH
 Comprehensive: CC, extended HPI,
complete ROS, complete PMH, FH and SH
E & M Coding
Level of Service Provided
Patient History Definitions
 HPI
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Elements: (Brief 1-3; Extended 4+)
Location
Duration
Severity
Modifying factors
Context
Timing
Quality
Associated symptoms
E & M Coding
Level of Service Provided
Patient History Definitions
 ROS
Definitions
 Pertinent=1
 Extended
2-9
 Comprehensive 10+
E & M Coding
Level of Service Provided
Organ Systems:
 Constitutional
 Eyes
 ENT
 Cardiovascular
 Respiratory
 GI
 GU
 Musculoskeletal
 Hematologic/Ly
mphatic
 Neurologic
 Endocrine
 Psychiatric
 Skin
 Allergic
E & M Coding
Level of Service Provided
Physical Exam Definitions
 Problem
focused: limited exam of
affected area
 Expanded PF: limited exam of affected
area and related systems
 Detailed: extended exam of affected
area and related systems
 Comprehensive: general multisystem OR
complete exam of affected system
E & M Coding
Level of Service Provided
Physical Exam Definitions
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Problem-focused: 1-5 elements in 1 or more
organ systems/body areas
Expanded problem-focused: 6 or more
elements in 1 or more organ systems
Detailed: at least 2 elements in at least 6
organ systems or body areas OR at least 12
elements in a single organ system
Comprehensive: All elements of at least 9
organ systems or body areas OR all elements
of one single organ system
E & M Coding
Level of Service Provided
Medical Decision Making
 Number
of possible diagnoses and/or
management options
 Amount or complexity of information
 Risk of complications, morbidity, and/or
mortality
E & M Coding
Level of Service Provided
Medical Decision Making
Number of possible diagnoses and/or management
options
 STRAIGHTFORWARD:
One self-limited or minor problem
 LOW COMPLEXITY:
*
*
*
*
One or two self-limited problem(s) or symptom(s)
One stable chronic illness
Acute self-limited uncomplicated illness or injury
Risk of complications, morbidity or mortality is low
E & M Coding
Level of Service Provided
Medical Decision Making

MODERATE COMPLEXITY:
* Three or more or self-limited problems
* One or more chronic problems with mild to
moderate exacerbation, progression or side effects
* 2 OR 3 stable chronic illnesses
* Undiagnosed new illness, injury or problem with
uncertain prognosis
* Acute illness with systemic symptoms
* Risk of complications, morbidity or mortality is
moderate.
E & M Coding
Level of Service Provided
Medical Decision Making

HIGH COMPLEXITY:
* One or more chronic illnesses with severe
exacerbation, progression, side effects
* Four or more stable chronic illnesses
* Acute complicated injury with significant risk of
morbidity or mortality
* Acute or chronic illnesses that pose a threat to life
or bodily function
* Abrupt change in bodily function (e.g., seizure,
CVA, acute mental status change)
* Risk of complications, morbidity/mortality is high.
Maximizing Office Coding
 Bill
for procedure, rather than E & M code
 Schedule procedures separately
 Bill for consults for pre-op H & P
 Utilize nurse visits
 How to code hospital admissions
 Other types of visits

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Nursing home
Home or “rest home”