Coding Tips Changes & Challenges

(1)

Coding Tips

Changes & Challenges

What

’

s New in 2008

CPT, ICD

-

9?

Perinatal Workshop Perinatal Workshop April, 2008 April, 2008

(2)

Code idea Perinatal Coders COCN AAP

CPT Application CPT Panel Facilitation

(3)

Disclosure

• I have the following financial relationships with the manufacturer(s) of commercial

product(s) and/or provider(s) of commercial services discussed in this CME activity:

• My content will/will not include discussion/ reference of any commercial products or services.

• I do/do not intend to discuss an unapproved/ investigative use of commercial

(4)

What will we discuss?

• Major renumbering for 2009!

• New codes

• Code revisions

• Code language changes

• Needed codes?

• Areas of compliance attention

• Repeated questions, concerns

(5)

Renumbering

• The following codes will be brought to a

separate section of CPT (code numbers

99460 series)

– Normal newborn

– Delivery room management – Critical care transport

– Critical care services – Intensive care services

(6)

Medical Team Conferences

99366

Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by non-physician qualified health care provider

99367

Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more;

(7)

Medical Team Conferences

99368

Medical team conference with

interdisciplinary team of health care

professionals, face-to-face with patient and/or family not present, 30 minutes or more, participation by non-physician

qualified health care provider 9936X4 Medical team conference with

patient/family and physician present (REJECTED)

(8)

Medical Team Conferences

• Face to face requirement

• Minimum of (3) health care participants

– Must be different specialties

– Must provide services to patient

– Must provide services within the last 60 days

• Physicians may report patient/family

present care with other E/M services

– Counseling represents >50% – Global code reporting?

(9)

Medical Team Conferences

• Must document their participation and their

suggestions

• May not report if you are contractually

connected to the hospital/facility

• Starts at the beginning of the review and

ends at the conclusion at the review

– Do not add report generation or record keeping time

(10)

New Telephone Codes

• 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

(11)

New Telephone Codes

• 98966

Telephone evaluation and

management service provided by a qualified non-physician health care professional 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

98967

11-20 minutes of medical discussion

(12)

E

-

mail Communications

• 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

communications network

(Do not report 99444 when using 99339-99340, 99374-99380 for the same communication’s])

(13)

Sick Admit Code

99477

Initial hospital care, per day, for

the evaluation and management of

the neonate, 28 days of age or less,

who requires observation, frequent

interventions and other intensive care

services

• For the initiation of inpatient care of the normal newborn report 99431

• For initiation of the care of the critically ill neon ate use 99295

• For initiation of inpatient hospital care for the neonate not

requiring intensive observation, frequent interventions or other intensive care services use 99221-99223

(14)

PICU Expanded Age

• Two new PICU codes approved and

valued this year: age 2 through 5

– 9929X1: admit code • 11.25 RVU’s • Times: 30/105/30 – 9929X2: subsequent days • 6.75 RVU’s • Times: 20/65/20

(15)

Infusion Services Guidelines

• Therapeutic infusion services codes

90760-90779 have been revised to

indicate that these codes are

not intended

for physician reporting in the facility

setting

. Rather in the facility these codes

are reported by the non-facility only. This

means in an office because the major

(16)

Modifier Language Revisions

• -22

• -25

• -51

• -58

• -59

• -76

• -78

(17)

Renumbered Codes Next Year

Tube thoracostomy with or without water seal

32551 32020

Thoracentesis with insertion of tube with or without water seal 32422

32002

Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent

32421 32000

Aspiration bladder; by needle 51100

51000

Descriptor New Code

(18)

New Code Proposals

What Have We Missed???

(19)

New Code Proposals

• Transitional care

– v. consultations

• Intensive care for infant >5 kg

– How many? What upper weight?

• Medical team conference with the family and physician present

– Reinstate the 4th _code?

(20)

Unvalued Services

• 99288

How do I value?

Could choose time based consult code,

time based ED code

(21)

Compliance Attention

(22)

Consultations

• Have been defined for the next year or two as the primary area of investigation and audit

review by CMS and the OIG.

• The main target is academic medical centers coding return visits for established patients as consults

• Also under review repetitive inpatient consults by same specialist

• Medicaid will follow at the state level and has also begun to focus on this area

(23)

CMS Consult Rule Changes

• NPP may order and provide consults

• IP consults only ONCE per hospital

– Subsequent care 99231-33

• OP consult may be repeated

• Written request must be included in the plan of care (OP) and in the orders (IP)

• If verbal request received both requester and consultant must document this in the record

• Consult cannot be “routinely” ordered

(24)

Consultations

A consultation initiated by a patient and/or family, and not requested by a physician

Or other appropriate source (eg, physician assistant, nurse practitioner, doctor of

chiropractic, physical therapist, occupational therapist, speech-language pathologist,

psychologist, social worker, lawyer, insurance company) e.g. prenatal consult

Is not reported by the consultation codes but by the office, home, domiciliary or rest home codes

(25)

Consultations

If subsequent to the completion of the consultation the physician assumes responsibility for a

portion or all of the patient(s) condition, the appropriate E/M codes for the site of service should be reported.

In the hospital setting the consulting physician

should use the appropriate inpatient consultation code for the initial encounter and then

subsequent hospital codes.

In the office setting the physician should use the appropriate office or other outpatient

consultation codes and then the established patient office or other outpatient services code

(26)

Resources

• Coding for Pediatrics

• Coding Hotline AAP

• [email protected]

• CPT 2008

• Medicare RBRVS 2008

• Coding Companion AAP

(27)

Continued Reduction in CMS

Work RVU

(28)

5Yr Review w

-

RVU Work Re

-

value

Of Discharge & Consult Codes

3.52 4.00 99255 2.90 3.29 99254 2.00 2.27 99253 1.32 1.50 99252 0.88 1.00 99251 1.67 1.90 99239 1.13 1.28 99238 2008 W-RVU 2007 W-RVU Code

(29)

5Yr Review w

-

RVU Work Re

-

value

Of Transport & Critical Care Codes

7.04 7.99 99296 16.26 18.46 99295 7.04 7.99 99294 14.07 15.98 99293 3.96 4.50 99291 2.11 2.40 99290 4.22 4.79 99289 2008 W-RVU 2007 W-RVU Code

(30)

5Yr Review w

-

RVU Work Re

-

value

Of The Inpatient Codes

1.76 2.00 99233 1.22 1.39 99232 0.67 0.76 99231 3.33 3.78 99223 2.25 2.56 99222 1.66 1.88 99221 2008 W-RVU 2007 W-RVU Code

(31)

Clarifications

(32)

Missouri Medicaid

State Medicaid decided to allow

submission and payment of the

global codes ONLY paid if the

neonatologists are in house for

24 hours!!!

(33)

CPT Assistant January 2008

• It is appropriate to report normal newborn

services on the same day that sick,

intensive or critical care services are

reported if the services are separated by

time.

• The critical care global codes do

NOT

require a 24/7 in house presence to report

them; “direct physician supervision” does

not require an in house presence.

(34)

Language Changes Associated

with Renumbering

• If two separate groups report critical

services on the same date the referring

physician reports hourly critical care

services and the receiving nursery reports

the global charge.

• It is appropriate to report procedures that

are part of the resuscitation even if the

neonate is admitted and receives a global

critical care code on the date of admission.

(35)

Coding Quagmires

(36)

Surfactant

• 94610 Intrapulmonary surfactant

administration by a physician through endotracheal tube

• Not part of “resuscitation”

• Cannot be given as convenience; must be clear evidence that the dose cannot wait until the

newborn is admitted to the nursery

• We do not wish to risk loss of ET and Lines in the DR

(37)

Billing at 2 Sites

• Same group cannot bill for services

provided at more than one site to the

same patient on the same date of service

– Group is considered single physician

– Services related to the same illness provided in the office, ED, observation and hospital on the same date of service by the same

physician or group only reports the hospital admit

(38)

Documentation

• Minimal audit requirements:

– “Critically ill”; requires “intensive care

services”; “continues to require hospital care” – Present body weight

– Physical presence

– Physical exam, can be focused

– Frequent evaluation (critical, intensive) – Review of data, studies, results

– Review of care plan with team – Clear involvement in MDM

(39)

EMR Reporting

• Carry over notes with repetitive data from previous days not useful and “concerning”

– Often notes have contradictory data and do not apply to the child’s condition on date of service

• Clear documentation of attendance

– Cannot be assumed by note or signature

• Match template to requirements

– Physical presence, frequency of evaluation, condition, weight, new data, exam, assessment, medical

(40)

The PATH Guidelines

Getting it Right!

(41)

Using NNP Notes

NNP’s are

NOT

covered by PATH!

Two questions to ask:

• Can the NNP practice independently?

• State nursing Board makes decision

• NNP must be approved for scope of practice

• Is the NNP employed by the hospital or

the neonatal group?

(42)

NNP Notes

• Licensed for independent practice and

hospital employed

– Can only use PFSH and ROS – No different from bedside nurse

– NNP costs already rolled into the Medicare and Medicaid cost reports

– “double dipping” – Stark violation

(43)

Correct Coding Practices

(44)

Critical Care

• Does the note state the child is critical?

• Do the parents understand the child is

critical?

• Does the “status” indicate critical?

• Is nursing staffing consistent with critical?

• Is there truly “highly complex medical

(45)

Critical Care

• How much face to face care was required?

• How many lab tests were required/reviewed?

• How much data was needed for review?

• How comprehensive was the physical exam?

• What technology is required?

• How unstable was the child?

(46)

The CPT Definition

• “Critically ill or injured” patient

• Acutely impairs one or more organ systems

• High probability of imminent or life threatening deterioration

• Highly complex medical decision making

• Both the illness and the treatment must meet the definition

• Interpretation of multiple physiologic parameters required

(47)

Critical Care Times / RVU

’

s

CODE

CODE IntraIntra--service timeservice time Work RVUWork RVU’’ss

• 99291 60’ 4.00 • 99223 45’ 2.99 • 99233 35’ 1.51 • 99293 180’ 16.00 • 99294 90’ 8.00 • 99295 245’ 18.49 • 99296 90’ 8.00 • 99298 30’ 2.75 • 99299 30’ 2.50

(48)

Use the Modifier

-

63

• Only for those procedures that are NOT

specific to neonates, e.g.:

– Lumbar puncture – Bladder taps – Bladder catheterization – Thoracocentesis – Thoracostomy – Pericardiocentesis – Peritoneocentesis

(49)

Immunization Counseling

• CPT and the RUC approved physician

work for

counseling parents

when

immunizations are provided

• Pediatric specific codes MD work:

– 90465 = 0.17 (<8yr, im/sc, first)

– 90466 = 0.15 (each additional)

– 90467 = 0.17 (<8yr, po/in, first)

(50)

1 or 2 Admissions ??

• Well newborn examined in the morning

and then gets sick later in the day.

– Same doctor: (2) admissions

• 99223 + 99431 • 99477 + 99431 • 99295 + 99431

• Hospital sick care admit later becomes

critical

– Same doctor: (1) code only upcode 99293 or 99477 to 99295

(51)

1 or 2 Admission(s) ??

• Admitted to floor early in the day; later

becomes critical and admit to NICU.

– Different doctor: (2) admissions

• 99221-23 or 99477 and 99295

• Admitted sick, hospital (1); admit critical

hospital (2)

– Same group: (1) code 99295

– Different group: (2) admit codes

(52)

1 or 2 Admission(s) ??

• Critical care admit hospital (1); transfer to

hospital (2) for critical care (higher level)

– Different group: (2) admissions

• 99293 or 99295 + 99293 or 99295

• Critical care admit hospital (1); transfer to

hospital (2) for critical care (higher level)

– Same group: (1) admission

(53)

1 or 2 Admission(s) ??

• Initial hospital sick code; (2) days

subsequent hospital care codes; day (4)

child becomes critical

– Same group:

• 99221-23 or 99477 on day (1) • 99231-33 or 99300 on day (2,3) • 99296

(54)

But I Spent A Lot More Time!

• Global codes do NOT allow for additional time

beyond the surveyed means

– Cannot switch back and forth from sick hospital codes and critical care codes simply based upon time you spend at bedside

• Can utilize either the -25 modifier or the

prolonged service codes (time based face to

face or non-face to face) for hospital sick care or consultative codes (not critical)

(55)

But I Am Not Being Paid!

• Correct coding must be utilized for fraud/abuse purposes EVEN IF the code is not being paid (NCCI edits/OIG)

– HIPAA gives private insurers same audits

• The AAP and its reimbursement committees must be informed and intervene for you

– State chapters of the AAP can help

• HIPAA can help with uniform reporting and payment policies

(56)

Neonatology 2008 Coding

Modifier

59 ₅₉

: Distinct Procedural Service

_{: Distinct Procedural Service}

• Used to identify procedures/services which

are distinct or independent from other

services or procedures performed on the

same day.

• This may represent:

– 1. A different session or patient encounter – 2. A different procedure or surgery

(57)