Transcript Putting it all Together for CPT

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PUTTING IT ALL
TOGETHER FOR CPT
Mona Fahoum, ND
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CPT Layout
• Evaluation & Management
• Anesthesiology
• Surgery
• Radiology
• Pathology/Lab
• Medicine
99201-99499
00100-01999
10040-69979
70000-79999
80000-89399
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 next week.
• 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/MLNProducts/Downloads/MASTER1.
pdf
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So, the audit tool
1.
2.
3.
HPI, ROS and PFSH
Exam
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 two-pillow orthopnea. He denies any headache,
dizziness, nausea or vomiting. He denies any lowerextremity 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.