Coding 101: The Basics. What precipitated this web seminar? Basics

Coding 101:

The Basics

Debbie Abel, Au.D. Director of Reimbursement American Academy of Audiology dabel@audiology.org

What precipitated this web

seminar?

• Questions that are posed to the Academy

• Concern about those questions

• Education of members

Basics

• Need a CPT, ICD-9-CM and HCPCS

manuals

– Can be purchased via:

• https://catalog.ama-assn.org/Catalog/home.jsp • http://www.ingenix.com/CodingResources/100040/ • http://www.decisionhealth.com/store/category.aspx?

CategoryId=PhysicianOffices-Coding-Books(DecisionHealth08)

Other resources:

• The American Academy of Audiology

•

Capturing Reimbursement

– www.audiology.org

• Centers for Medicare and Medicaid (CMS)

For Medicare Providers:

• Local Coverage Determination Policies (LCDs):

– Requirements from contractor

– May describe what is “medically necessary”

• CPT • ICD-9

– Your contractor may not have an LCD

• Not a negative, but look at others (by state, alphabetically or by contractor):

– http://www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp

Medicare Tenent:

• If you are a Medicare provider, cannot bill a

Medicare patient more than you do another

patient for the same procedure

Therefore…

• You cannot perform free hearing

evaluations

• Why would we want to de-value our own

services?

– Retail vs medical?

– Impact on autonomy and recognition – Medicare isgoing to do that…

Thoughts:

• These three coding systems support each

other for filing claims

• Required:

– CPT (and/or HCPCS) ANDICD-9

• If billing HCPCS codes

– May also be billing CPT

– Always have to have an ICD-9 code with each claim

Coding Mantra:

• Need to code by signs and/or symptoms

• Code by patient complaints

– Tinnitus? – Hearing loss? – Dysequilibrium?

Need Outcome Measures!

• With MIPPA

– Audiologists now have access to Physician Quality Reporting Initiatives (PQRI)

• Need outcome measures

Check Out:

–Audiology Clinical Practice Algorithms and Statements

• http://www.audiology.org/NR/rdonlyres/0BFA4442-81FA-

4D06-A60A-C56DF888BAD3/0/ClinicalPracticeAlgorithms.pdf

Thoughts:

• Case-building for differential diagnosis • Differentiates us from non-audiology providers • Provides our worth in the healthcare system • Provides your worth to the facility that employs

you

– Many are evolving into reimbursing you via relative value units (RVU) reimbursement

Considerations:

• CPT codes selected must be obvious to an

insurance company as to why they were

selected

• CPT codes must be ones typically

performed by audiologists

• CPT codes must mesh in supporting the

diagnosis code you have chosen

Current Procedural Terminology (CPT) AND

International Classification of Diseases (ICD-9)

• Have to support each other

• It needs to be apparent that what you performed would result in the disease code chosen

• What is being billed has to be appropriate to what you are licensed to perform

• Documentation has to reflect the above points

Avert the denial:

• Do NOT use unspecified hearing loss codes

• Unless there is no other choice • Likely to be denied

Thoughts:

• May utilize several ICD-9’s on the same

claim:

– Example:

• Patient presents with a unilateral hearing loss and tinnitus:

– 389. 16 sensorineural hearing loss, asymmetrical – 388.31 subjective tinnitus

– Medicare may only allow one ICD-9 per CPT code

ICD-9 Recommendations:

• When looking for diagnostic or disease

codes, 5 digits are the most specific

– Less prone to denials

• Avoid those that are 3 and 4 digit and those

than end in 0

• Diagnostic V codes are also to be avoided

ICD-9 vs ICD-10

• ICD-9 has 17,000 codes

• ICD-10 has 68,000 codes

• Will need 5010 HIPAA standard for

ICD-10

– Utilize 4010 HIPAA standard for ICD-9

• Proposed deadlines

– April 1, 2010 for 5010 – October 1, 2011 for ICD-10

Many opponents, implemention

may be delayed:

• American Health Information Management Association (AHIMA)

• American Medical Association (AMA) • American Academy of Professional Coders

(AAPC)

• Extensive amount of professional health care organizations

• Large amount of hospital and medical offices

ICD-10-CM

• Will be alphabetic and numeric:

– H912 Sudden idiopathic hearing loss – H931 Tinnitus

CPT Codes

• Procedures

• Examples:

– 92557 Basic comprehensive audiometry

• Currently the only audiology bundled code:

– 92553 (Pure tone air and bone conduction audiometry) – 92555 (SRT) and 92556 (WRS)

– CPTTM _{five-digit codes, descriptions, and other data only are}

copyright 2007 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in

– CPT.TM_CPTTM _{is a trademark of the American Medical}

CPT Codes (cont.)

• Vestibular codes:

• Audiologic procedures:

– CPT 92551-92583

• Evoked potential codes:

– CPT 92585-6

• OAE codes:

– CPT 92587-8

CPT Codes (cont.)

• Hearing aid related codes:

• Cochlear implant codes:

– CPT 92601-92604

• Central auditory test codes:

• Tinnitus code:

CPT Codes (cont.)

• Audiologic (aural) rehabilitation

• “Nameless codes”----unlisted

otorhinolaryngological service or procedure

Modifiers

• -22 Unusual Procedural Services

• Utilized when procedure is greater than what is typically required

– Involves increase in provider work, time and complexity of what is typically performed

» Many insurance carriers state that if it is less than 25% more work, should not append

» May yield a 20-50% increase of the allowable rate – Example: 92557-22

Modifiers (cont.)

• Requires documentation to be submitted

attesting to why additional time and/or work

was necessary

• An audit and/or a delay in payment may

occur

Modifiers (cont.)

• -26 Professional component

• ENG (CPT 92541-92548) • ABR (CPT 92585) • OAE (CPT 92587, 92588)

– Utilized:

• When someone else performed the procedure • You do the interpretation and prepare the report

Modifiers (cont.)

• TC Technical component

– Utilized with:

• ENG (CPT 92541-92548) • ABR (CPT 92585) • OAE (CPT 92587, 92588)

– Utilized:

• When you only performed the test

– Bill TC

• Another provider does the interpretation

– They bill –26

• This equals the same reimbursement as the global fee • Example: 92585-TC

Modifiers (cont.)

• -52 Reduced services

– Procedure is partially reduced or eliminated

• Discontinued at provider’s discretion after the procedure commenced

• Can be used to indicate monaural vs binaural testing • Not recognized by all carriers

• Example: 92557-52

Modifiers (cont.)

• -53 Discontinued procedure

– Procedure started, patient’s well being becomes jeopardized during the procedure, provider discontinues

– Example: Patient having ototoxicity monitoring, becomes ill during procedure

• Reimbursed at 25% of the allowed amount • Example: 92557-53

Modifiers (cont.)

• -76 Procedure was performed more than

one time on the same date of service

– Glycerol or urea test – Ototoxicity monitoring

Medicare Modifiers

• GY-Item or service is statutorily excluded or does not meet the definition of any Medicare benefit

– Often used when a secondary insurance has a hearing aid benefit

– On the Office of the Inspector General’s list for 2009

• GA-Waiver of liability on file

– To be used when a denial is expected and an ABN is on file

• No ABN, no billing the patient

Medicare Modifier (cont.)

•

GZ

-Item or service expected to be denied as

not reasonable and necessary

– To be used when a denial is expected and an ABN is not on file

Medicare Considerations:

• Medicare Participating Provider:

– Medicare pays you 80% of the allowable amount per the Medicare Physician Fee Schedule

Medicare Non-Participating

• Non-participating categories:

• 5% less than participating

– Limiting charge

• 10% higher than participating

Medicare Non-participating

• Patient pays you their 80% allowable and

difference in the limiting fee

• You bill Medicare

• Medicare pays the patient 80% of the

allowable amount per the Medicare

Physician Fee Schedule

Another category:

• Opting out

– Need a contract with Medicare – Need a contract with the patient – Cannot file any claims to Medicare – Can’t “return” to Medicare for 2 years

“Dying isn’t hard. Getting paid

by Medicare is.”

-Art Buchwald, 2006

Advanced Beneficiary Notice of

Noncoverage (CMS-R-131)

• Released in March, 2008

• Was to be a one-year phase-in

• Should be utilized now

• Required as of March 1, 2009

• ABN and Notice of Exclusions of Medicare

Benefits (NEMB) are now on the same form

• Patient directs how the claim is to be filed

Three options on the ABN:

• Three options:

For those things that are

statutorily excluded:

• Anything not medically necessary • What is medical necessity?

– May be located in the LCD

– Needed for the diagnosis or treatment of a medical condition

– Provided for the diagnosis, direct care and treatment of the patient’s medical condition

– Meets the standard of good health practice

– Is not for the convenience of the patient or health care practitioner

“Incident to” billing

• Does not pertain to diagnostic audiology

procedures

– Has not been applicable since at least 2002 – Audiologic procedures are classified as “other

diagnostic tests”

– Other “diagnostic tests” cannot be billed “incident to”

What

IS

“Incident to?”

• Furnished in a institutional setting to non-institutional patients

• An “integral, though incidental, part” of the service of a physician in the course of diagnosis or treatment of an injury or illness

• Commonly furnished without charge or included in the physician’s bill

• Of a type commonly furnished in the office or clinic of a physician

• Furnished under the “direct supervision” of the physician and furnished by a physician, other practitioner, or “auxiliary personnel”

“Incident to”…a professional issue

• CMS transmittals 84 and 1470 (issued on

February 29, 2008)

– Specifies that audiologists are to utilize their own National Provider Identifier (NPI) when filing claims to Medicare

• Also need a Provider Identifier Number (PIN)

Another transmittal…

• CMS transmittal 1550:

– “For claims with dates of service on or after October 1, 2008, audiologists should enroll in the Medicare program. 6061.1

– For claims with dates of service on or after October 1, 2008, the NPI of the enrolled audiologist shall be used on claims in the appropriate rendering and billing fields.”6061.2

Addresses:

• Audiologists need to file:

– 855R

• Clarification of SLP and audiologic services

Also…

– Otolaryngologists can no longer be (and should NOT have been) billing audiologic services with their own provider numbers

– Effective date was initially set for April 7, 2008 – CMS extended the deadline until October 1,

If you are a contractor or

employee of a physician, need to

file an 855R to reassign the

benefits to the physician

http://www.cms.hhs.gov/cmsforms/downloads

/cms855r.pdf

Reimbursed by way of the same

physician fee schedule as the

physician

We are reimbursed at 80% of the

allowable Medicare Physician

Other components of CMS

Transmittal 84:

• http://www.entnet.org/Practice/upload/R84

BP.pdf

– “Contractors shall not pay for services provided using computer administered tests that do not require the skills of an audiologist”

• 5717.8

CMS Transmittal 84

• “Contractors shall not pay for the technical

component of audiologic diagnostic tests

performed by a qualified technician unless

the physician or nonphysician supervisor

who provides the direct supervision

documents clinical decision making and

active participation in delivery of the

service.”

– 5717.14

CMS Transmittal 84

• “Contractors shall not pay audiologists for

treatment services.”

CMS Transmittal 84

• “Contractors shall pay for services that

require the skills of an audiologist when

furnished by an audiologist qualified

according to section 1861 (II)(3) of the

Act.”

– 5717.17

http://www.ssa.gov/OP_Home/ss

act/title18/1861.htm

CMS Transmittal 84

• “Contractors shall not pay for services that

require the skills of an audiologist when

furnished by an AuD 4

_{year student or}

others who are not qualified according to

section 1861 (II)(3) of the Act.”

In the supporting information:

• Cannot deny payment if the diagnosis is

sensorineural hearing loss

– Patient may have had a change in their hearing or other related concerns

• Needs to be vetted and the only way is an evaluation

Supporting info (cont.)

• “Computer administered tests or devices

such as the device that produces an

“otogram” do not require the skills of an

audiologist (interpretation, comparison,

consideration, or modification, during the

tests) and can be administered by any staff.

Such tests are screening and not

audiological diagnostics tests.”

Further…

• “With the exception of screening tests and tympanograms, audiologic function tests with medical diagnostic evaluation require the skills of an audiologist. For vestibular function tests, it may be appropriate for a physician or qualified nonphysician practitioner with the skills of an audiologist to directly supervise and provide the skills of an audiologist while the services are being furnished by a technician.”

And finally…

• “Although AuD 4

_{year students and other}

audiology students do not meet the current

requirements to statute to provide audiology

services, they may meet standards

equivalent to audiology technicians.”

4

_{Year AuD Students}

• Can see Medicare patients IF:

• Supervisor has to be in the booth with the student

– On-going decision making is discussed/directed – Supervisor can bill Medicare for services if this

condition is met

– Student may help write the report

Evaluation and Management

Codes (E/M)

• Time, complexity and review of systems are

required

• Medicare will not reimburse audiologists at

this point in time for E/M codes

• BE CAREFUL:

– Audiologists should not upcode-be realistic with what you are doing

• Personal thought: would not code beyond a level 3 so as not to trigger an audit

E/M

• New and established patient codes

–Established: CPT 99211-99215

Need to include Review of

Systems (ROS):

• Head, including the face

• Neck

• Chest, including breasts and axilla

• Abdomen

• Genitalia, groin, buttocks

• Back

• Each extremity

ROS (cont.)

• Eyes

• Ears, nose, mouth and throat • Cardiovascular

• Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin

• Neurologic • Psychiatric

E/M Codes

• CPT 99201

– A problem focusedhistory – A problem focusedexamination – Straightforward medical decision making

• Physicians typically spend 10minutes face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT 99202

– An expandedproblem focused history – An expandedproblem focused examination – Straightforward medical decision making

• Problems are of low-moderate severity

• Physicians typically spend 20minutes face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT 99203

–Medical decision making of low complexity

• Problems are of moderate severity

• Physicians typically spend 30 minutes face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT 99204

– A comprehensive history – Acomprehensiveexamination – Medical decision making of moderate

complexity

• Problems are of moderate to high severity • Physicians typically spend 45 minutes face-to-face

with the patient and/or family

E/M Codes (cont.)

• CPT 99205

– A comprehensive history – Acomprehensiveexamination

– Medical decision making of high complexity

• Problems are of moderate to high severity • Physicians typically spend 60 minutes face-to-face

with the patient and/or family

E/M Codes (cont.)

• CPT code 99211

– May not require a physician’s presence – Minimal problem

– Typical time spent: 5minutes

E/M Codes (cont.)

• CPT code 99212

– A problem focusedhistory – A problem focusedexamination – Straightforward medical decision making – Problems are minor

– Physicians typically spend 10 minutes face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT code 99213

– An expandedproblem focused history – An expandedproblem focused examination – Problems are of low to moderate severity – Medical decision making of lowcomplexity – Physicians typically spend 15minutes

face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT code 99214

– Medical decision making of moderate

complexity

– Physicians typically spend 25minutes face-to-face with the patient and/or family

E/M Codes (cont.)

• CPT Code 99215

– Medical decision making of highcomplexity – Problems are of moderate to high severity – Physicians spend 40minutes face-to-face with

the patient and/or family

Cerumen Management-69210

• Is in the scope of practice of audiology

• Unless cerumen is impacted, should not be

billing for it separately as it is “included” in

the CPT code

• Can be billed to the patient with the

CMS-R-131, the new ABN/NEMB form and the

appropriate modifier

CPT Code 92579-VRA

• According to the vignette, it is not a method code:

“The audiologist then proceeds to the control room and, through the diagnostic audiometer, presents speech stimuli and frequency specific sounds between 500 hertz and 4000 hertz.”

“When and frequency specific minimum response levels between 500 hertz and 4000 hertz, the audiologist enters the patient side of the audiometric test booth and informs the mother of the results.”

CPTTM _{five-digit codes, descriptions, and other data only are copyright 2007 by}

the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in

– CPT.TMCPTTM is a trademark of the American Medical Association.

CPT Code 92582: CPA

for pulsed tones at a comfortable loudness level, say to the child, "Listen to this!", and hold just the earphone adjacent to the child's ear. This is repeated two or three times until the child demonstrates that he is no longer afraid of the presence of the earphone.”

• “The search for minimum response levels is repeated for each frequency from 250 hertz through 6000 hertz for the right and left ears, respectively.”

CPTTM five-digit codes, descriptions, and other data only are copyright 2007 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in

– CPT.TMCPTTM is a trademark of the American Medical Association.

--Nothing noted about speech audiometry…

New CPT code for 2009!

• CPT code 95992

HCPCS Codes

• Healthcare Common Procedure Coding System (HCPCS) • Addresses what CPT did not with:

– Some services

• V5010 (Assessment for hearing aid) • V5020 (Conformity evaluation) – Supplies:

• Hearing aids • Dispensing

• Earmolds (and earmold impression) • Batteries

• Assistive Listening Devices

Options:

• Unbundling vs bundling

– Gives the practitioner the option to unbundle – Gives the insurance company the option to

bundle

– Gives the patient and the applicable third party payor the mechanism to demonstrate

professional value

Standardized Billing Form:

The CMS 1500

Interactive CMS 1500:

http://www.palmettogba.com/Internet

/cms1500.nsf/CMS1500.html#

www.noridianmedicare.com/macj3b/

forms/cms1500/instructions.html

ICD-9-CM

International Classification of Diseases

Conductive Hearing Loss -389.0

• 389.00 Conductive Hearing Loss (CHL), unspecified

• 389.01 CHL, external ear • 389.02 CHL, tympanic membrane • 389.03 CHL, middle ear

• 389.04 CHL, inner ear • 389.05 CHL, unilateral • 389.06 CHL, bilateral

• 389.08 Conductive HL of combined types

Sensorineural Hearing Loss-389.1

• 389.10 Sensorineural hearing loss, unspecified

• 389.12 Neural hearing loss, bilateral • 389.13 Neural hearing loss, unilateral • 389.14 Central hearing loss

• 389.15 Sensorineural hearing loss, unilateral • 389.16 Sensorineural hearing loss, asymmetrical • 389.17 Sensory hearing loss, unilateral

Mixed CHL and SNHL Hearing

Loss-389.2

• 389.20 Mixed hearing loss, unspecified

• 389.21 Mixed hearing loss, unilateral

• 389.22 Mixed hearing loss, bilateral

Other

• 389.7 Deaf, non-speaking, not elsewhere

classifiable

• 389.8 Other specified forms of hearing loss

• 389.9 Unspecified hearing loss

Diagnostic V codes

• V72.1 Examination of ears and hearing

• V72.11 Encounter for hearing examination

following failed hearing screening

• V72.19 Other hearing examination of ears

and hearing

• Last resort, likely to be denied

Claim form:

• Lists the CPT(s), ICD-9(s) and HCPCS

codes and demonstrates their interaction:

– What you performed (CPT) – Diagnosis results (ICD)

– Resulting recommendations if product (HCPCS)

• Ties the coding systems together

Questions?

To ask a question, please type your question into the chat box in the lower left corner of the screen and click on the “Send” button located right below the box.

Documentation

• A chart is a legal document

• Provides continuity of care between health

care professionals

• Third party payor requirement

• Quality Assessment/Peer Review

What should be included?

• Demographic information

– Address – Date of birth – Contact information – Insurance card

• Photocopy front and back (need address)

– Driver’s license

What else?

• Who is the referring professional if required

by a third party payor

• Medicare physician referrals:

– On the physician’s letterhead or prescription pad

– Not to have the appearance that it was solicited by you

• No referral pads with your practice name

And?

• Reason for the visit

• Case history

– Surgeries

– Medications, past and present

• Herbals, over-the-counter meds

– Occupational noise exposure – Recreational noise exposure

More…

• HIPAA forms

– Notice of Privacy Practices (NPP)

• Case history

– Adult

• Familial hearing loss

– Age of onset, syndromes? – Treatment plan

» Surgeries? Amplification?

• May have to excavate for the history…

More…

• Pediatric:

• Prenatal • Delivery • Family

Chart Notes:

• “If it isn’t in the chart, it didn’t happen…”

• Need to document all that patient relays to

you

SOAP

• Subjective findings

– History

• Objective finding

– Physical exam – Testing

• Assessment

– Puzzle piecing

• Plan

– Recommendations for patient based on the above – Referrals to others

Hard Copy Guidance

• If err, strike through with one single line

No sticky notes!

Everything needs to be secured with

the patient’s name and date…

Further…

• Initial with your three initials

• Do not use white out

• Do not scribble

• Do not shred

Electronic Health Care Records

EHR/EMR

• President Bush has requested this to be a

reality by 2014

– To reduce errors – Portability – Accessibility

EMR Stumbling Blocks:

• The average cost of an EMR per physician or provider is $33,000!

• Implementation:

– $100 per hour for customization, training, and IT setup ($3,500)

• Accessibility:

– One tablet PC per provider =$2,500

– One workstation for each member of your support staff =$1,000

– Network server =$2,000

EMR

• Can enter all applicable information for that

particular date of service

• Can utilize templates

EMR

• Once you hit the button to enter all

information, cannot append for that date of

service

• Can append with appendix or appendices

Contracting-the new reality show??

• Fear Factor?

– Everyone else will so I have to…

• Survivor?

– Will I be paid enough to keep the doors open?

• Lost?

– In the legalese?

• The mole?

– Are we blindly walking into something that may not be beneficial to the practice?

Contracting

• Need to know if you can afford to be a

provider:

– Overhead costs, practice expenses? – Number of patients you can expect? – Do you have to give something(s) away? – Balance billing? Under what conditions? – What may be a beneficial arrangement for the

practice down the street may notbe for you

Contracting (cont.)

• Need to know what your monthly break

even point is

• Need to know with each separate contract

what you can (or can’t afford) to loose

• Sacrifice diagnostics for product?

– If so, how much of a cost

• Personally • Professionally

Contracting tenets:

• As long as it is not contractually excluded, a

patient should expect to pay for services,

diagnostic or rehabilitative.

Insurance is a mechanism for

reimbursement, not payment

-

Kadyn Williams, AuD

Patients are expected to pay for

their assigned health care costs

-Supposed to deter fraud and abuse

Final Questions?

To ask a question, please type your question into the chat box in the lower left corner of the screen and click on the “Send” button located right below the box.

Thank You!

Debbie Abel, Au.D.

Director of Reimbursement

American Academy of Audiology

703.226.1024

dabel@audiology.org

Contact Info: