Paula M Wright, CPC, CPMA, CPC‐I, CEMC
The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is depended upon clinical judgement and the nature of the upon clinical judgement and the nature of the presenting problem(s). 1995 and 1997 Documentation Guidelines 4/5/2011 2011 CODING UPDATES 2 • Over document –Word processing software –Electronic medical record
Formatted note systems
–Formatted note systems • Facilitate –Carry over –Fill in –Auto‐populate 4/5/2011 2011 CODING UPDATES 3 • Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries
the previous entries.
• Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary.
4/5/2011 2011 CODING UPDATES 5 4/5/2011 2011 CODING UPDATES 6 Paula M Wright, CPC, CPMA, CPC‐I, CEMC • Afluria Vaccine, 3 yrs & >, IM
Q2035
Q2035
• Flulaval Vaccine, 3 yrs & >, IMQ2036
Q2036
• Fluvirin Vaccine, 3 yrs & >, IMQ2037
Q2037
• Fluzone Vaccine, 3 yrs & >, IMQ2038
Q2038
• NOS, 3 yrs & >, IMQ2039
Q2039
4/5/2011 2011 CODING UPDATES 8• 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health physician or other qualified health care professional; first vaccine/toxoid component • 90461 each additional vaccine/toxoid component 4/5/2011 2011 CODING UPDATES 9 DtaP intramuscular administration: 90460 90461 90461 90700 (CPT Vaccine code reported in addition) 4/5/2011 2011 CODING UPDATES 10 Coding for a 2‐month‐old infant based on current immunization schedule DTaP (IM) Admin: 90460, 90461, 90461 Vaccine: 90700
Rotavirus (oral) Admin: 90460 Vaccine: 90681 Hepatitis B and Haemophilus p p Admin: 90460, 94061 influenza type b (IM)
, Vaccine: 90748 Inactivated Poliovirus (IM) Admin: 90460
Vaccine: 90713 Pneumococcal conjugate vaccine, 13 valent (IM) Admin: 90460 Vaccine: 90670
TOTAL: 90460 X 5 and 90461 X 3
4/5/2011 2011 CODING UPDATES 11 90654 – Influenza virus vaccine, split
virus preservative free for
virus, preservative‐free, for
intradermal use
90664 – Influenza virus vaccine, pandemic formulation, live, for intranasal use 90666 – Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use intramuscular use 90667 – Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use 90668 – Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use 4/5/2011 2011 CODING UPDATES 13 • Coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS) for an individual who:
– is no longer within the 12 months of the effective date ofis no longer within the 12 months of the effective date of Medicare Part B coverage period, and –has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. • CR7079: Effective January 1, 2011:Implementatin April 4, 2011 –http://www.cms.gov/transmittals/downloads/R2109CP.pdf 4/5/2011 2011 CODING UPDATES 14 • G0438 – Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit.
• G0439 Annual wellness visit; includes a • G0439 – Annual wellness visit; includes a personalized prevention plan of service (pps), subsequent visit. 4/5/2011 2011 CODING UPDATES 15 • Establishment of an individual’s medical/family history • Establishment of list of current providers and suppliers that are regularly involved in providing medical care • Measurement of height, weight, BMI (or weight
circumference if appropriate) BP and other routine circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on patient’s medical/family history • Detection of any cognitive impairment that the patient may have • Review of patient’s potential (risk factors) for depression or mood disorders, past or present using appropriate tools 4/5/2011 2011 CODING UPDATES 16
• Review of patient’s functional ability and level of safety based on direct observation….
• Establishment of a written screening schedule for the patient for the next 5‐10 years…
• Establishment of a list of risk factors and conditions for which primary secondary or tertiary interventions are which primary, secondary, or tertiary interventions are recommended….. • Furnishing of personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services…… • Any other element(s) determined appropriate by the Secretary of Health and Human Services through he National Coverage Determination (NCD) process. 4/5/2011 2011 CODING UPDATES 17 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at 2 of these 3 key components: 99224 99225 99226 • Problem focused interval history • Problem focused examination • Straightforward or low complexity medical decision making • Expanded problem focused interval history • Expanded problem focused examination • Moderate complexity medical decision making • Detailed interval history • Detailed examination • High complexity medical decision making 4/5/2011 2011 CODING UPDATES 18 11042 – Debridement, subcutaneous tissue (includes epidermis & dermis if performed); first 20 sq cm or less 11045 – each additional 20 sq cm or part thereof 11043 – Debridement, muscle &/or fascia (includes epidermis,
dermis subcutaneous tissue if performed); first 20 sq cm
4/5/2011 2011 CODING UPDATES 19 dermis, subcutaneous tissue if performed); first 20 sq cm or less 11046 – each additional 20 sq cm or part thereof 11044 – Debridement, bone (includes epidermis, dermis, subq tissue, & muscle &/or fascia if performed); first 20 sq cm or less 11047 – each additional 20 sq cm or part thereof • G0440 Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less • G0441 Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; each additional 25 sq cm 4/5/2011 2011 CODING UPDATES 20