Transcript Coding Compliance

Coding Compliance for the Chiropractic
Practice 2015
Anthony W. Hamm, DC, FACO
Coding Resources
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AMA CPT primary source reference
ICD-9-CM (10)
RBRVS CPT code values (CMS driven)
HCPCS codes
• ChiroCode Deskbook, 2015
CPT Coding
• Choose the code that best describes the service
provided
• Codes reported should be within the scope of
practice of the provider and be clinically indicated
Telling the Story
• Both documentation AND code reporting tell the
story of the patient encounters
• Diagnoses tell why we did something
• Level of exam indicates the complexity of patient
condition
Evaluation & Management
• Office/Outpatient services 99201-99215
• Most scrutinized codes by carriers
• Most common mistakes are due to misinterpretation
of descriptions and definitions
• Must understand concept of key components
Terminology
• New Patient-A new patient is one who has not received professional
services from a provider or another provider of the same specialty who
belongs to the same group practice within the past 3 years
• Established Patient-A patient who has received professional services
within the past 3 years from the provider or another provider of the same
specialty who belongs to the same group practice
• Chief Complaint-A concise statement from the patient describing the
symptom, problem, condition, diagnosis, or other factor that identifies the
reason for the visit
Terminology (cont)
• Concurrent Care-When more than one provider provides services to a
patient on the same day. Payment for concurrent care is determined by
establishing medical necessity for services performed by more than one
provider
• Counseling-A discussion with the patient and/or family regarding
diagnoses, test results, medication management, care instructions,
prognosis, or other factors related to the patient’s condition
• History of Present Illness-A chronological description of the
development of the patient’s present illness, or problem from onset to
present. This must be documented by the provider and not ancillary staff
Terminology (cont)
• Medical Decision Making-The process for describing the
outcome of the visit, through consideration of the nature of the
presenting problem, diagnoses, treatment and/or management
options, diagnostic tests and procedures ordered, complexity of the
condition and risk for complications
• Morbidity -The quality or state relative to a disease process
• Mortality -The number of deaths in a given time or place
Terminology (cont)
• Nature of Presenting Problem -A disease, condition, illness, injury, sign, finding or complaint
for which the patient is being seen. The five types are:
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Minimal–Services may not require the presence of a provider, however, services are
rendered under a provider’s supervision
• Self-Limited or Minor–A problem that typically runs a definite course, is transient in
nature, and not likely to permanently alter health status
• Low Severity–A problem in which the risk of morbidity without treatment is considered to
be low; there is minimal risk of mortality without treatment; and full recovery is expected
• Moderate Severity–A problem for which the risk of morbidity without treatment is
moderate; there is moderate risk of mortality without treatment or there is some uncertainty
of the prognosis or potential for functional impairment
• High Severity–A type of problem in which the risk of morbidity and/or mortality without
treatment is high to extreme. There exists a high probability of severe or prolonged
functional impairment
Terminology (cont)
• Past History -A review of the patient’s own medical history
related to trauma, illness, previous surgeries and hospitalizations,
including medications, allergies and other pertinent information
• Social History -A review of events and activities describing the
patient’s lifestyle, e.g.. marital status, education, employment, sexual
history, substance use or other relevant social factors
• Review of Systems-An inventory of the body systems acquired
through a series of questions asked to the patient. The review of
systems helps define possible management options
Terminology (cont)
• Face to Face Time -This includes only the time the
provider spends face to face with the patient obtaining the
history, performing the examination and counseling the
patient and/or family
• Consultations –Services provided by a provider whose
opinion or advice is requested for a specific condition or
problem by another provider or an appropriate source
Components of E/M Services
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History *
Examination *
Medical Decision Making *
Counseling
Coordination of Care
Nature of Presenting Problem
Time
• * Key Components
History
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Four Types:
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Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
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Components that determine the extent of history obtained:
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1.Chief Complaint/History of Present Illness:
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2. Review of Systems:
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Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Signs and Symptoms
Constitutional, Eyes, Ears/Nose/Throat/Mouth, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integument,
Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
3. Past, Family, Social History:
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Past History, Family History, Social History
After Determining which level of each history component is applicable, choose the
overall level of history:
HPI
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ROS
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PFSH
N/A
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Level of History
Brief
N/A
Problem Focused
Brief
Problem Pertinent N/A
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
Expanded Problem Focused
Examination
• Four Types:
• Problem Focused –A limited examination of the affected body area or organ
system.
• Expanded Problem Focused –A limited examination of the affected body
area or organ system and other symptomatic or related organ system(s).
• Detailed –An extended examination of the affected body area(s) and other
symptomatic or related organ system(s).
• Comprehensive –A general multi-system examination or a complete
examination of a single organ system.
Examination
• Body areas
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Head, including Face
Neck
Chest, including Breasts and Axilla
Abdomen
Genitalia, Groin, Buttocks
Back
Each Extremity
Examination
• Organ Systems
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Eyes
Ears, Nose, Throat, & Mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurological
Psychiatric
Hematological/Lymphatic/ Immunologic
Examination
• Constitutional: Measurement of any 3 of the
following 7 vital signs:
• Sitting or Standing Blood Pressure
• Supine Blood Pressure
• Pulse Rate and Regularity
• Respiration Rate
• Temperature
• Height
• Weight
Examination
• General Appearance
• Development
• Nutrition
• Deformities
• Body habitus
• Grooming
Examination
• Cardiovascular
• Exam of the vascular system by observation (swelling,
vasoconstriction etc.), palpation (pulse, temperature,
edema, tenderness) or auscultation (heart sounds, murmurs,
bruits).
Examination (MSK elements)
• Gait and Station
• Exam of joints, bones, muscles, and tendons of 4 of the
following 6 areas:
• Head and Neck
• Spine, Ribs and Pelvis
• Right UE
• Left UE
• Right LE
• Left LE
Examination (MSK elements)
• Examination of a given area includes:
• Inspection, percussion, palpation, with notation of any
misalignment, asymmetry, defects, tenderness, masses or
effusions.
• Assessment of Range of Motion (ROM) noting any
restriction, pain, crepitus, contracture, etc.
Examination (MSK elements)
• Assessment of Stability noting any
joint fixation, laxity, subluxation,
dislocation, etc.
• Assessment of Muscle noting
strength, atrophy, spasm, abnormal
movement, etc.
Examination (MSK elements)
• Skin: Inspection and/or palpation of the skin and
subcutaneous tissue (scars, rashes, lesions, ulcers, etc.)
in 4 of the following 6 areas:
• Head/Neck
• Trunk
• Right UE
• Left UE
• Right LE
• Left LE
Examination (MSK elements)
• Neurological & Psychiatric
• Coordination and/or proprioception UE & LE
• Reflexes (deep tendon, pathological)
• Sensory (touch, proprioception)
• Mental Status (orientation to time/ place/person)
• Mood and Affect (depression, anxiety, agitation, etc.)
Medical Decision Making
The complexity of establishing a diagnosis and/or selecting a
management option is measured by the following 3 elements:
• 1. The number of possible diagnoses and/or number of management
options that must be considered
• 2. The amount and/or complexity of medical records, diagnostic tests,
and/or other information that must be obtained, reviewed and analyzed
• 3. The risk of significant complications, morbidity and/or mortality, as well
as co morbidities associated with the patient’s presenting problem(s), the
diagnostic procedure(s) and possible management options
Medical Decision Making
• Four Types of Decision Making:
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Straight Forward
Low Complexity
Moderate Complexity
High Complexity
• Determine the type of decision making by choosing which levels
of risk qualify for each element of medical decision making. Two
out of three elements must be met or exceeded to qualify for any
given level of decision making.
Medical Decision Making
Number of DX
Amount and/or
Or Management +
Risk of Complications
Complexity of Data+
and/or Morbidity or =
Options
to be Reviewed
Mortality
Decision Making
Minimal
Minimal/None
Minimal
Straight Forward
Limited
Limited/Low
Low
Multiple
Moderate
Moderate
Extensive
Extensive
High
Type of
Low Complexity
Moderate Complexity
HighComplexity
Office or other outpatient services New
Patient 99201-99205
For a new patient, all three key components must be met or exceeded to qualify
for a particular level of service. The overall level of service is selected based
on the performance and documentation of history, examination, and medical
decision making.
Office or other outpatient service Established
Patient 99211-99215
For an established patient, two of the three key components must be met or
exceeded to qualify for a particular level of service. The overall level of service
is selected based on the performance and documentation of history,
examination, and medical decision making.
Preventive Services
• Extent and focus of the service largely depends on
the age of the patient
• If an abnormality is encountered then a separate
E/M service may be indicated
• Counseling and anticipatory guidance /risk factor
reduction interventions
Preventive Services
• New patients
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99381: age under 1 year
99382: age 1-4 years
99383: age 5-11 years
99384: age 12-17 years
99385: age 18-39 years
99386: age 40-64 years
99387: age 65 years and over
Preventive Services
• Established patients
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99391: age under 1 year
99392: age 1-4 years
99393: age 5-11 years
99394: age 12-17 years
99395: age 18-39 years
99396: age 40-64 years
99397: age 65 years and over
Special E/M Services
• Work Related or Medical Disability
Evaluations by Treating Physician (99455)
• Completion of medical history
• Performance of examination
• Formulation of diagnosis, assessment of
capabilities and stability, calculation of
impairment
• Development of treatment plan
• Completion of necessary documentation
Special E/M Services
• Work Related or Medical Disability Evaluations By
Other Than Treating Physician (99456)
• Completion of medical history
• Performance of examination
• Formulation of diagnosis, assessment of capabilities and
stability, calculation of impairment
• Development of treatment plan
• Completion of necessary documentation
ICD-9-CM (10)
• International Classification of Disease-Clinical
Modification (ICD-CM) is a universally accepted coding
nomenclature that defines patient diagnosis
• Providers place the appropriate ICD-9-CM code(s) on the
CMS-1500 form in Box #21
• Always use accurate diagnosis codes and customize the
diagnosis for each patient
• While patients may have similar conditions, each presents
a unique clinical picture
ICD-9-CM
Documentation must support the diagnosis codes you
use. For example, if you bill for an ankle adjustment,
a diagnosis involving the ankle is required and it must
be supported by documented examination findings
ICD-10-CM comes on-line October 1, 2015
Be Prepared
Diagnostic Examples
• Neurological
• Radiculopathy (723.4, 724.4)
• Neuropathy (sciatica w/o discopathy 355.0)
• Headaches (784.0, tension 307.81, migraine 346.00)
• Structural
• Degenerative Joint Disease (715.8)
• Degenerative Disc Disease (722.4, 722.51, 722.52)
• Spondylolisthesis (738.4)
Diagnostic Examples
• Last 2 digits indicate specific region
• Functional
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Restricted Range of Motion (719.58)
Deconditioning, muscle wasting (728.2)
• Soft Tissue
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Myalgia, myofascial pain (729.1)
• Extremity
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Bursitis (726.10* shoulder)
Carpal Tunnel Syndrome (354.0)
Meniscus injuries (717.3 medial, 717.4 lateral)
Telephone Evaluation Services
• 99441 Telephone evaluation and management
service provided by a physician to an established
patient, parent, or guardian not originating from
a related E/M service provided within the
previous 7 days or leading to an E/M service or
procedure within the next 24 hours or soonest
available appointment; 5-10 minutes of medical
discussion
• 99442 11-20 minutes of medical discussion
• 99443 21-30 minutes of medical discussion
Telephone Evaluation Services
• These codes are used to report episodes of care
initiated by an established patient or guardian of
an established patient
• Bill E/M instead of these codes if the telephone
service ends with a decision to see the patient
within 24 hours/next available appointment or if
the telephone call refers to an E/M service
performed within the previous seven days or
within the postoperative period of a procedure.
On-Line Evaluation
• 99444 Online evaluation and management
service provided by a physician to an established
patient, guardian, or health care provider not
originating from a related E/M service provided
within the previous 7 days, using the Internet or
similar electronic communication network.
• Reportable services are those that include that
physician’s timely response to a patient’s inquiry
and require that the physician permanently store
(electronically or in hard copy) the encounter.
Disability Evaluations
• Work Related or Medical Disability Evaluations by
Treating Physician (99455)
• Completion of medical history
• Performance of examination
• Formulation of diagnosis, assessment of capabilities and
stability, calculation of impairment
• Development of treatment plan
• Completion of necessary documentation
Disability Evaluations
• Work Related or Medical Disability Evaluations
By Other Than Treating Physician (99456)
• Completion of medical history
• Performance of examination
• Formulation of diagnosis, assessment of capabilities
and stability, calculation of impairment
• Development of treatment plan
• Completion of necessary documentation
CMT
• The expected distribution of codes by Medicare is
approximately:
• 98940: 35%
• 98941: 55%
• 98942: 10%
CMT
• 5 Spinal regions
• Cervical including atlanto-occipital
• Thoracic including posterior ribs
• Lumbar
• Sacrum
• Pelvis including SI joints
CMT
• 98940: One to two spinal regions
• 98941: Three to four spinal regions
• 98942: Five spinal regions
CMT
• Extraspinal regions
• Head including TMJ
• Upper extremities
• Lower extremities
• Anterior ribs
• Abdomen
CMT
• 98943, 1 or more extra-spinal regions
• Correlate:
• Symptoms
• Exam findings
• Diagnosis
• Treatment
• Documentation
CMT Work Valuation
• Pre-service
• Intra-service
• Post-service
CMT Documentation
• Subjective record of the patient’s complaint.
• Physical findings to support manipulation in a region.
• Assessment of change in a patient’s condition, as
appropriate.
• Record of specific segments manipulated.
Reporting E/M with CMT
• You may bill a separate E/M code on the same
day as a CMT in the following situations:
• A new patient visit.
• An established patient with a new condition.
• A new injury, re-injury, aggravation, exacerbation, or
re-evaluation to determine if a change in treatment
plan is necessary.
• Reporting of E/M services with CMT should be
supported by appropriate documentation.
Physical Medicine Services
• Supervised modalities
• Do not require one-on-one contact by the provider
• May be billed only once per encounter
• Code 97012 (mechanical traction) is an example of a
supervised modality
Physical Medicine Services
• Constant attendance procedures
• Require direct one-on-one patient contact by
provider.
• Billed once per 15-minute unit.
• Code 97032 (manual electrical stimulation) requires
constant attendance.
• Code 97035 (ultrasound) also requires one-on-one
provider attendance.
Therapeutic Exercises 97110
• Used to develop strength and endurance, range of
motion, and flexibility (one parameter).
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Treadmill for endurance
Isokinetic exercise for ROM
Lumbar stabilization exercises for strength
Gym ball for flexibility
Neuromuscular Reeducation 97112
• Used when describing those activities that affect:
• Movement
• Proprioception
• Balance
• Coordination
• Kinesthetic sense
• Posture
Therapeutic Activities (97530)
• AKA: Kinetic Activities.
• Used when multiple parameters are involved,
including balance, strength, and range of motion.
• Must be related to a functional activity with direct
functional improvement expected.
• Billed in 15-minute increments.
Massage (97124)
• Massage is a passive procedure used for restorative
effect.
• Massage includes effleurage, petrissage, and/or
tapotement (stroking, compression, and/or
percussion).
• It is an independent procedure from CMT and is
considered separate and distinct.
Manual Therapy (97140)
• Includes soft tissue and joint
mobilization, manual traction, trigger
point therapies, passive range of
motion, myofascial release, etc.
• Add -59 modifier when reported with
CMT
Temporary S Codes
• “Temporary national codes (non-Medicare). The
S codes are used by the Blue Cross Blue Shield
Association and the Health Insurance
Association of America to report drugs, services
and supplies for which there are no national
codes but for which codes are needed by the
private sector to implement policies, programs or
claims processing. They are for meeting the
particular needs of the private sector.”
Temporary S Codes
• Verify with insurers to determine if they will
accept the S codes
• S9090--Vertebral axial decompression, per
session
• AMA CPT has indicated that CPT 97012 should
be billed for verterbral axial decompression
• S8948--(Application of a modality [requiring
constant provider attention] to one or more
areas; low-level laser; each 15 minutes.
Unlisted Modalities(97039)
• When reporting an unlisted code to describe a
procedure or service, it will be necessary to
submit supporting documentation (e.g.
procedure report) along with the claim to
provide an adequate description of the nature,
extent, need for the procedure, and the time,
effort and equipment necessary to provide the
service.
• 97039--Hydro-Bed Therapy
• 97039--Infratonic
Acupuncture
• 97810
• Acupuncture, one or more needles; without electrical stimulation,
initial 15 minutes.
• 97811
• Acupuncture, one or more needles; without electrical stimulation,
each additional 15 minutes.
• 97813
• Acupuncture, one or more needles; with electrical stimulation, initial
15 minutes.
• 97814
• Acupuncture, one or more needles; with electrical stimulation,
additional 15 minutes.
Acupuncture
• Reported in 15-minute increments.
• Time based on direct one-on-one
contact with the patient, not duration
of needle(s) placement.
• Reported with or without electrical
stimulation.
• E/M may be reported separately.
Functional Testing
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Manual Muscle Testing (95831-95834)
Range of Motion Testing (95851-95852)
Physical Performance Testing (97750)
Testing and measurements are taken and compared
to a standardized grading scale.
• A formal written and signed report of the findings is
made, including the comparison analysis.
Imaging
• Radiology Codes – normally global
(both professional and technical
component)
• Professional Component -26 modifier
• E/M Component
• Consultation on X-ray made elsewhere
Imaging
• When you are the treating physician, use the appropriate
E/M code (e.g., 99212).
• When you are not the treating physician, you can bill for
re-reading x-rays with the code 76140.
Modifiers
• -25: Separately identifiable E/M service
• -59: Distinct procedural services
• -76: Repeat procedure by the same physician
Up-coding, Down-Coding and
Bundling
• ACA and many other national associations have
formal position statements that oppose bundling
and down coding that is inconsistent with CPT
billing intent.
• ACA Policy can be found in the ACA Chiropractic
Coding and Compliance Manual.
• You are entitled to bill according to CPT intent
for your services.
• If codes are bundled or down coded
inappropriately, use this policy to appeal the
claim.
Up-Coding
• Up coding is an intentional act by a
provider to inflate a code to a higher
level (e.g., reporting 99204 when
99203 would be more appropriate).
• This should be avoided and may be
considered evidence of fraud.
Coding Abuse
• On a final note, make coding work for you by following the
recommendations of experts
• Don’t get caught up in schemes that sound too good to be true (vendor
suggestions)
• Don’t be part of the small percentage of providers who abuse the
reimbursement system and cast suspicion on the entire profession
• Consistent patterns of incorrect coding can trigger investigations and
recoupment efforts
• Data mining/retrospective reviews by insurers can show a business pattern
of inappropriate code use which can be interpreted as fraud
ACA Template Appeal Letters
• If you use the E/M codes and modifiers correctly
and are still denied, here’s what you can do.
• Refer to the E/M Template Letter in the ACA
Coding and Compliance Manual.
• This will alert the insurer to correct policy and is an
excellent appeals mechanism, if needed.
THE END