Transcript Spectrum Billing

POH/DMC UROLOGY
Grand Round Conference
Presented by: Spectrum Billing Technologies, LLC
Coding & Compliance
Teaching Hospital
• A hospital engaged in an approved
Graduate Medical Education (GME)
residency program in Medicine,
Osteopathy, Dentistry, or Podiatry
Teaching Physician
• Teaching physician is a physician
(other than a resident) who involves
residents in the care of his or her
patients
Payment
• Payments under the physician fee
schedule are made if the services are
furnished by a physician, jointly by a
physician & resident, or by a resident
in the presence of a teaching
physician
E&M Payment Under the
Physician Fee Schedule
• A personal notation must be made by
the teaching physician demonstrating
his/her presence in the history,
exam, and medical decision making
with a brief, summary comment
related to the resident’s entry to
confirm or revise key elements
Surgical Procedure Payment
Under the Physician Fee
Schedule
• In the case of a surgical procedure,
the teaching physician must be
present during all critical portions of
the procedure and must be
immediately available to furnish
services during the entire procedure
Minor Procedure Payment
Under the Physician Fee
Schedule
• The teaching physician must be
PRESENT for the entire procedure
“Billing Codes”
• CPT CODE
Describes WHAT
was done
• ICD9 CODE
Describes WHY it
was done
CPT Code Defined
• CPT codes describe medical
procedures and services
• All CPT codes are 5 digit codes
• Each CPT code represents the
universal definition of a service or
procedure
CPT, Continued
• CPT coding controls the health care
provider’s reimbursement
• Accurate CPT coding provides
effective communication of medical
services among healthcare entities
CPT/ICD9 Relationship
• The ICD9 code must provide an
indication of MEDICAL NECESSITY
for the service (CPT code) provided
• Insurance companies “link” each type
of service with specific diagnosis
codes that support the “reason” for
the service
Evaluation & Management
• Outpatient E&M services require a
differentiation for new vs
established patients
• Code selection will affect the
provider’s reimbursement….new
patient codes are paid a higher rate
New vs Established
Patient
• A new patient is one who has not received
any professional services from the
physician (or specialty group) within the
past 3 years
• An established patient is one who has
received professional services from the
physician (or group) within the past 3
years
New Patient Coding
• New patient outpatient Evaluation &
Management codes are 99201,
99202, 99203, 99204, and 99205
• The “level” of service is determined
by 3 Key Components of the
visit…History, Exam, Medical
Decision Making
Established Patient
Coding
• Established patient Outpatient E& M
Codes are 99211 (Nurse Visit),
99212, 99213, 99214, and 99215
• The “level” of service is determined
by 3 Key Components of the
visit…History, Exam, Medical
Decision Making
Chief Complaint
• A concise statement describing the
symptom, problem, conditions,
diagnosis or other factor that is the
reason for the encounter, usually
stated in the patients words…..
Past Family Social
History
• A review of medical events in the
patient’s family that includes
information about parent, sibling,
children health history
• Specific diseases related to
problems identified in the chief
complaint
PFSH, cont.
• Diseases of family members which
may be hereditary or place the
patient at risk
• Patient history, surgery, obstetrics,
illness, injury, immunization, etc.
• Tobacco, alcohol, drugs, violence, diet
History of Present
Illness
A chronological description of the
development of the patient’s present
illness from the first sign and/or
symptom to the present (location,
quality, severity, timing, context,
modifying factors and associated
signs and symptoms).
Review of Systems
An inventory of body systems
obtained through a series of
questions seeking to identify signs
and/or symptoms which the patient
may be experiencing, or has
experienced….i.e. weight gain,
abnormal bleeding, masses, etc.
Examination
• General multi-system exam or a
single organ system exam may be
performed by any physician
regardless of specialty
• The content of the exam is selected
based on clinical judgement, patient
history, and the nature of the
presenting problem
Medical Decision Making
• Diagnosis AND/OR management
options
• Amount/Complexity Data
• Risk of Complications
Counseling – Coordination
of Care
When counseling/coordination of
care dominates more than 50% of
the visit….time may be considered
the key or controlling factor for a
particular level of E/M service.
Counseling
Counseling is a discussion concerning
one or more of the following areas:
• Diagnostic results, impressions,
and/or recommended diagnostic
studies
• Prognosis
Counseling, cont.
• Risks & Benefits of management
options
• Instructions for treatment and/or
follow-up
• Importance of compliance with
treatment options
Counseling, cont.
• Risk factor reduction
• Patient education
Time
•
•
•
•
•
99201
99202
99203
99204
99205
– 10 min
– 20 min
– 30 min
– 45 min
– 60 min
•
•
•
•
•
99211 – Nurse Visit
99212 – 10 min
99213 – 15 min
99214 – 25 min
99215 – 40 min
NEW PATIENT & CONSULTATIONS
3 KEY COMPONENTS REQUIRED
A new patient is a patient who has not received any professional services from the physician or another physician of the
same specialty who belongs to the same group practice within the last 3 years.
CODE
99201 99241
99202 99242
99203 99243
99204 99244
99205 99245
HISTORY
EXAM
Problem Focused
Problem Focused
Exp. Problem Focused Exp. Problem Focused
Detailed
Detailed
Comprehensive
Comprehensive
Comprehensive
Comprehensive
ESTABLISHED PATIENT
MEDICAL DECISION
MAKING
Straightforward
Straightforward
Low
Moderate
High
TIME
10 Min
20 Min
30 Min
45 Min
60 Min
2 KEY COMPONENTS REQUIRED
An established patient is a patient who has received professional services from the physician or another physician of the
same specialty who belongs to the same group practice within the last 3 years.
CODE
99211
99212
99213
99214
99215
HISTORY
EXAM
Nurse Visit
Problem Focused
Problem Focused
Exp. Problem Focused Exp. Problem Focused
Detailed
Detailed
Comprehensive
Comprehensive
MEDICAL DECISION
MAKING
Straightforward
Low
Moderate
High
TIME
5 Min
10 Min
15 Min
25 Min
40 Min
Consultation Coding
• Outpatient consultation codes are
99241, 99242, 99243, 99244, and
99245.
• Inpatient consultation codes are
99251, 99252, 99253, 99254, and
99255
Consultations
• The request and need for the
consultation must be documented in
the patient’s medical record
• All services provided and the
resulting “advice or opinion” must be
provided in writing to the requesting
physician
Consultations, Cont.
• Consultation services are reimbursed
at a higher rate than the Out-Patient
or In-Patient E & M Services
Initial Hospital Care
• Only one physician may submit an
initial hospital care code for the
same patient (99221, 99222, 99223)
• Co-Admitting physicians must decide
who will bill initial hospital care
• If both do, the first claim received
will be paid, with the second rejected
Subsequent Hospital
Care
• Hospital visit codes are used to
report DAILY services (99231,
99232, 99233)
• Multiple visits on the same day, by
the same physician, must be reported
as 1 visit with a higher level code
incorporating both visits
Concurrent Hospital Care
• Providing similar hospital visits to the
same patient..by multiple physicians..
on the same day..with the same
diagnosis..will likely be denied
• Avoid using the “admitting” diagnosis
• Code for the SPECIFIC reason YOUR
SPECIALTY saw the patient
Hospital “Floor Time”
• Hospital Services (Initial &
Subsequent) include the time the
physician is present at the patient’s
bedside and on the unit to include
time spent reviewing the chart,
writing notes, exam time, and
coordination of the patient’s care
Hospital Discharge
• 99238 - Hospital discharge day
management; 30 minutes or less
• 99239 – Hospital discharge day
management; more than 30 minutes
ICD9 Coding Defined
• The “reason” for procedures,
services, and supplies are converted
into ICD9 Diagnosis Codes
• Codes identify diagnosis, symptoms,
conditions, problems, complaints or
other reasons for service
Suspected Conditions
• If a diagnosis is questionable,
probable, likely, or rule out code the
signs, symptoms, or complaints
• Avoid reporting a diagnosis code that
is not proven…use signs, symptoms,
complaints
Complications
• Complications are responsible for
many procedures therefore the
complication should be coded
• For example:
998.5 Postoperative Infection
997.3 Respiratory Complications
Questions ???