Coding and Billing – a Global Perspective
Prepared for the American Academy of Orthopaedic Surgeons “Business, Policy, and Practice Management in Orthopaedics” Lecture SeriesWilliam Beach, MD and Julie Balch Samora, MD, PhD, MPH Objectives:
1. Gain a basic understanding of the various terms, concepts, and abbreviations involved in coding and billing.
2. Develop an educated approach to coding and billing with particular emphasis on office and surgical coding and billing.
3. Provide real examples of appropriate coding and billing. Table of Contents:
1. Introduction
2. Essential Vocabulary 3. Surgical Coding
4. Evaluation and Management 5. Conclusion and Key Points Key Takeaways:
1. Choose a target level of service, which is appropriate for new (99203) and established (99213 or 99214) patient visits.
2. Understand the variations of each level for the established patient. If you inject or aspirate, write a prescription, or plan on surgery, you should be able to document adequate information to qualify for 99214.
3. If you are billing or plan to bill 99204 or 99205, you must examine four body areas and document 30 bullet points in the physical exam key component. 4. Do not forget the 2 of 3 (data, diagnosis or plan/risk) for Medical Decision
Making (for new and established patients).
5. For audit purposes only, you only have to pass audit muster on 2 of 3 key components for established patients. Consider taking an audit pass on the physical exam of the established patient. You should always examine the patient, but may not necessarily need the level of detail that the auditor requires (e.g., blood pressure).
Chapter 1: Introduction
There are volumes of information on the subject of billing and coding. However, the information is often inappropriate for different levels of expertise and may be more confusing than helpful. In addition, the topic is so mundane that it approaches boring. However, the legal mandate to practice correct coding coupled with the huge fines assessed in the absence of correct coding make this aspect of practice essential. With these concerns in mind, our goal is to present the basics without a laborious discussion: “Just the facts!”
Chapter 2: Essential Vocabulary
Coding and billing require knowledge of several abbreviations and the coding building blocks.
1. Common Procedural Terminology (CPT) is the overarching alphanumeric system that represents “all” physician services. The Editorial Panel of the AMA is responsible for maintenance and changes to the CPT codes. Examples of CPT codes are 99203 (level 3 new patient office visit) and 29888 (arthroscopic ACL reconstruction).
2. Centers for Medicare and Medicaid Services (CMS) - the largest purchaser of healthcare services in the world. In addition, CMS has many programs to insure correct coding and billing, such as Recovery Audit Contractors (RAC), Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT), etc.
3. Relative Value Units (RVU) – procedures are “ranked” via comparative analysis against all other procedures. The unit of measure is the relative value unit.
4. The Relative Value Update Committee (RUC) is composed of physicians and other coding experts from large specialty societies as well as representatives from insurance and CMS.
5. CPT Code Modifiers - “…indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.” There are many instances when you will bill a service or multiple services and many of the CPT codes will have a modifier (or two-digit number) appended to them, which identifies a special
situation. When a bill for physician services is prepared, one or often more than one CPT code numbers are listed, in descending order of RVU’s. After the first CPT code, known as the index code, the physician/biller must assist the payor by providing rationale for why more than one code is being listed. Below is a description of when, who and which of the many different
The following segment is from “AMA Physicians’ Current Procedural Terminology” presented by Richard J. Freidman, MD at the “Coding and Reimbursement Update 2008” at the American Academy of Orthopaedic Surgeons, Chicago, IL. 2008.
a. Modifiers – When
i. Multiple procedure or same procedure performed more than once
ii. Service(s)/procedure provided within the global services period of another service/procedure
iii. Indicate occurrence of unusual events b. Modifiers – Who
i. Any and all health care providers ii. Use modifiers “pro-actively”
iii. Make them a part of your coding regimen c. Modifier Format
i. Two digit appendage to a CPT code
ii. Example – 29827-22 = “arthroscopic rotator cuff repair, a massive cuff tear.” We use the 22 modifier for increased procedural services to indicate when the work required to provide a service is substantially greater than typically required such as a massive rotator cuff tear.
iii. May use more than one modifier
iv. Example – fracture care that required a second procedure within the global services period (usually 90 days) in a morbidly obese patient – 27506-22-58. We use the 22
modifier for increased procedural services (the work required to provide a service is substantially greater than typically required such as an obese patient) & the 58 modifier for staged or related procedure or service by the same provider during the post-operative procedure.
d. Modifier Breakdown
i. Evaluation & Management – 21, 24, 25, 26 ii. Altered services – 22, 52, 53
iii. Assistants – 80, 81, 82
iv. Pre & Post-op care – 54, 55, 56 v. Multiple surgeons – 62, 66 vi. Add-on – 47
vii. Multiple procedures – 50, 51, 59 viii. Repeat procedures – 76, 77, 78, 79
ix. Miscellaneous – 57
e. Example. The most common modifier used is the 59 modifier. Under certain circumstances, it may be necessary to indicate that a
procedure or service was distinct or independent from other non-Evaluation & Management (E&M) services performed on the same day. Modifier 59 is used to identify procedures or services (again,
distinct from E&M services) that are not normally reported together but are appropriate under the circumstances. If you list multiple procedures you should append the 59 modifiers to all the secondary procedures to inform the insurer that each code you list is a separate, billable procedure.
Chapter 3: Surgical Coding
Coding for orthopedic surgeons is divided into two main categories: Evaluation & Management (E&M) and Surgical. We will begin our discussion with Surgical. Surgical coding is by far the easiest from a coding standpoint because of the establishment of “bundling packages.” CMS uses a third party bundling package known as the “National Correct Coding Initiative.” The American Academy of Orthopaedic Surgeons has an excellent bundling package, the “Global Services Data Book” which is the definitive package for orthopedic surgical billing. The bundling package lists every surgical procedure/CPT code and which codes can and cannot be listed for reimbursement with that code.
A bundling package defines which surgical CPT codes can be reimbursed either separately or in combination. For example, 29880 is the CPT code for a medial AND lateral meniscectomy. Therefore, several codes would be bundled together or billing for multiple procedures would be “disallowed” by the bundling package. These bundled procedures include:
1. 29881 – medial OR lateral meniscectomy is obviously included with medial AND lateral.
2. 28982 – medial OR lateral meniscal repair cannot be reimbursed when you have performed a meniscectomy.
3. 28983 – medial AND lateral meniscal repair cannot be reimbursed when you have performed a meniscectomy.
This example illustrates the next “valuable” point. With rare exceptions when submitting your billing documentation, when more than one procedure on a single date of service (during one case) is performed, you are expected to list the
procedure with the highest number of RVUs first. The exception for sports
medicine/arthroscopic coding is the case of meniscectomy and chondroplasty. The CPT coding instructions (book or electronic) occasionally includes information on how to code a procedure or set of procedures. As per CPT, if you perform a meniscectomy (medial or lateral or both) you cannot also list the chondroplasty code. It does not matter in which compartment the meniscectomy was performed or where the chondroplasty was performed. Thus, by CPT there is a hard and fast rule for not being reimbursed for 29877 (arthroscopic chondroplasty) and
Another scenario: If you perform a 29883 (medial AND lateral meniscal repair) and also “trimmed” a portion of the meniscus you would not list 29881 or 29880
because:
1. You cannot charge for both a repair and a removal.
2. The reimbursement for a repair (29882 or 29883) is substantially better than for a removal (29880 or 29881), as it should be. Remember the
reimbursement is based on the number of RVUs a procedure is given is based on the RUC. The RUC uses time and intensity to determine the RVUs.
If you perform several procedures in one surgical setting, example – arthroscopic rotator cuff repair, acromioplasty, distal clavicle resection and biceps tenodesis. This procedure would be coded:
1. Arthroscopic rotator cuff repair – 29827
2. Arthroscopic biceps tenodesis – 29828, 59 modifier
3. Arthroscopic distal clavicle resection – 29824, 59 modifier 4. Arthroscopic acromioplasty – 29826
Several points need to be made regarding this process. First, list the procedure with the highest number of RVU’s in the first position (again, this is known as the index procedure or index code). Second, whenever secondary procedures are listed, the surgeon should append a “modifier” to those codes. The exception to that rule is an arthroscopic acromioplasty (29826). As of 2012, 29826 was created as an “add-on” code. It cannot be listed alone. So no modifier is necessary, as it must always be placed in an “add-on” or secondary position.
Why do we use surgical coding modifiers? We want the insurer/payor to know why we are submitting more than one code for reimbursement.
Chapter 4: Evaluation and Management (E&M)
Evaluation and management services are the “non-surgical” services we provide: office, emergency room and hospital patient visits. For the purposes of this project, we will focus on the outpatient office visits. The basics of outpatient coding are the 1995 or 1997 Documentation Guidelines for Evaluation and Management Service. Neither is technically preferred but the 1997 guidelines are more “bullet” based and make counting individually required data points easier.
Whether you use an electronic medical record or a paper chart, templates will facilitate your data acquisition and documentation. If one uses an intake data sheet, which asks patients to provide all the information required by CMS and insurers for each level of service, this greatly facilitates the process. The codes under discussion are 99201-99205 (new patient visits) and 99211-99215 (established patient visits). Key Components to both new and established patient visits
2. Physical Examination (PE) 3. Medical Decision Making (MDM) New Patient Visits
Chief Complaint and History
Every medical record must have a chief compliant. There must be a reason why the patient is seeking medical attention! The history requirements are listed in the table below with the level of service for each required amount of documentation.
99201 99202 99203 99204 99205
The history is essentially the same information that a good medical student documents.
A. Chief complaint
B. History of present illness/pain a. Character b. Location c. Onset d. Duration e. Intensity f. Exacerbation g. Remission h. Associated symptoms
C. Review of systems – there are 14 systems noted in the 1997 Guidelines. D. Past medical history
a. Medical b. Surgical
c. Medications d. Allergies E. Social a. Marital history b. Children c. Occupation d. Smoking e. Alcohol F. Family history
a. Cause of death of relatives b. Diseases or illness of relatives
From a practical standpoint, the patient should provide all the information to achieve a level 5 history at every visit. All the provider has to do is facilitate that exchange of information. That can be done on paper, electronically or a
combination of the two. Paper templates are available and most EMR’s support this data acquisition.
Physical Examination
Knowledge of several basic rules is mandatory to understand the correct documentation for the PE.
1. There are only six recognized body parts (2 upper extremities, 2 lower extremities, back and neck).
2. There are a maximum of 30 available data points.
3. Templates are very helpful to assure all the required documentation has been completed.
4. TRIM (Tenderness, Range of motion, Instability or stability and Muscle strength) is the pneumonic coined by Jack Ritchie, MD to remind him of the necessary exam points for each body part.
99201 1 body part 99202 1 body part 99203 2 body parts 99204
4 body parts 4 body parts 99205
The goal is that every new patient visit is a level 3 physical exam! This means we must document 12 bullets, which is easily achievable. If you are using an EMR and are achieving meaningful use you will likely have to record the blood pressure, height and weight. What exactly does ‘meaningful use’ mean? Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services Incentive Programs that governs the use of electronic health records and allows eligible
providers and hospitals to earn incentive payments by meeting specific criteria. The true goal of meaningful use is to promote the use of EMRs. If not you do not need the vital signs for EMR purposes, you can still obtain twelve bullets. Document the following (normal or not):
1. Well developed & well nourished (or not)
2. Stands with a normal weight bearing line (or not) 3. Alert and oriented X 3
4. Normal affect
5. Tenderness – affected extremity 6. Range of motion – affected extremity 7. Instability or stability – affected extremity 8. Muscle strength – affected extremity 9. Tenderness – unaffected extremity 10. Range of motion – unaffected extremity 11. Instability or stability – unaffected extremity 12. Muscle strength – unaffected extremity 13. Skin condition
14. Pulses 15. Sensation
16. Coordination/balance
Rationale – use the normal extremity to determine the expectation of the abnormal extremity. Very important is to realize that a level 4 or 5 new patient visit requires 30 bullets which = all the bullets available from vitals signs to lymph node exam!
Medical Decision Making
Medical decision making is the most complicated part of the medical record for several reasons:
1. There are three sections in medical decision making. a. Data
b. Diagnosis c. Risk
2. The rules require, from an audit/documentation rules standpoint, that the medical record must qualify in only 2 of the 3 areas of medical decision making.
For example if the goal is always to document a new level 3 visit then we need to attain the required number of bullets in 2 of 3 areas in MDM (data, diagnosis and/or plan/risk). That goal is easily attainable for the normal new patient visit.
1. Data – interpretation of an image = 2 points or reviewing a report/summary = 2 points. 99203 requires a total of 2 points from this area.
2. Diagnosis – an established problem which is worse (the normal situation when a patient presents to the office for an evaluation) = 2 points. If this problem is new and does not require a work-up = 3 points and if it does require a work-up = 4 points. 99203 requires 2 points from this area. 3. Risk/plan – components of this section are divided into plan elements and
risk elements. Only one item is required in this area. a. Over-the-counter medications – plan
c. A radiograph – risk
d. Arterial puncture – risk and plan
e. The standardized risk required to meet 99203 is an ankle sprain (ICD 845.02).
99201 99202 99203 99204 99205
To summarize, the medical record will be reimbursed at the lowest level of the three key components and is 100% dependent on documentation. There should always be a level 5 history (use templates!!). There should always be a level 3 physical exam (12 bullets), which is the rate limiting key component for a new patient visit. Finally, if you obtain a radiograph or interpret an image, if the patient has a
worsening problem that is new or requires a work-up, and you suggest an OTC med, recommend PT or if patients have a problem equal to or greater than an ankle sprain, then the level of documentation has met the requirements of 99203.
Established Patient Visits
Chief Complaint and History
The requirements for an established patient are less strenuous because the
Guidelines realize that most of the information has already been obtained, i.e. some of the information has not changed. Specifically, for audit purposes only for
established patient visits, you are only required to meet documentation
requirements for 2 of the 3 key components (history, physical exam or MDM). While you must always provide as much information as possible, for audit purposes you could argue to a chart auditor that you can pass on one of the three key
components. If you perform a level 5 history, a level 2 physical exam and a level 4 medical decision making, you would expect to be reimbursed for a level 4
established patient visit (99214). This is due to the fact that you are permitted an audit pass on one key component. We would suggest for established patients to take the audit pass on the physical exam because that is the rate limiting factor in your new patient visit.
99212 99213 99214 99215
Using the same simple intake form for new patients (or using a specific follow-up form), a level 5 history is taken for every patient. The requirements are noted in the table above.
Physical Exam
With the 2 of 3 rule allowing an audit pass on one of the key components, the physical exam is the obvious choice for the pass. The physical exam is the rate limiting component in the new patient exam. Remember, the physical exam must be performed, but from an audit standpoint, take an audit pass. Requirements are as follows: for a focused exam (99212), only 1 bullet is needed; for an expanded exam
(99213), 6 bullets; for detailed (99214), 12 bullets, and finally for a comprehensive exam (99215), all 30 bullets must be obtained.
Medical Decision Making
Medical decision making is very similar to the new patient categories. The only practical difference for the established patient is the number of points awarded for each category and satisfying a bullet. Remember, that for medical decision making, you must only satisfy the documentation requirements in 2 of the 3 categories (2 of 3 rule for MDM).
99212 99213 99214 99215
A routine established patient will be either a level 3 or 4 visit (99213 or 99214). How? For a level 3 (99213) established patient, a radiograph is interpreted (2 points). Two minor problems or one worsening problem create 2 points. For risk, all that is required is an over the counter medication, physical therapy prescription, an x-ray/arterial puncture/biopsy or a single problem. Any two of these satisfy the documentation requirements for 99213.
For example, if an advanced image is obtained prior to the visit, the radiograph and advanced image could be interpreted. If the advanced image report is reviewed then the data requirements have been met for 99214 (2 points for interpretation of the image and 1 point to review the report = 3 points). If there are two diagnoses and one is worsening then three points are given = 99214. If any of the following are provided, a level 4 visit is documented:
1. Aspiration or injection of a joint. 2. Write a prescription.
3. Plan surgery.
4. Have obtained an MRI, CT, bone scan or x-rayed two body parts. 5. Exacerbation of 2 chronic problems.
Remember, documentation is paramount! In Summary:
New Patient Visit = 99203
1. Level 5 history - intake sheet
2. Physical exam – 12 bullets in 2 body areas (level 3 and the “level limiting charge factor”)
3. MDM
a. Data – interpret a radiograph
b. Diagnosis – a worsening problem or two established problems c. Risk – prescribe PT/OTC, obtain a radiograph.
Established Patient Visit (99213 or 99214) 1. Level 5 history – intake sheet
2. Physical exam – audit pass with appropriate information documented 3. MDM (rate limiting charge factor- any two of the following = level 4
otherwise level 3)
a. Interpret an image and read a report
b. Two diagnoses which are major or worsening and may require work-up
c. Aspirate and/or inject, write a script or schedule surgery
Lastly, how could an auditor determine quickly if you are an orthopedic compliant coder? Two quick audit inquiries; 1) level 4 or higher new patient visits (99204 or 99205) or 2) level 5 established patient visits (99215).
Chapter 5: Conclusion and Key Takeaways:
1. Choose a target level of service, which is appropriate for new (99203) and established (99213 or 99214) patient visits.
2. Understand the variations of each level for the established patient. If you inject or aspirate, write a prescription, or plan on surgery, you should be able to document adequate information to qualify for 99214.
3. If you are billing or plan to bill 99204 or 99205, you must examine four body areas and document 30 bullet points in the physical exam key component. 4. Do not forget the 2 of 3 (data, diagnosis or plan/risk) for Medical Decision
Making (for new and established patients).
5. For audit purposes only, you only have to pass audit muster on 2 of 3 key components for established patients. Consider taking an audit pass on the physical exam of the established patient. You should always examine the patient, but may not necessarily need the level of detail that the auditor requires (e.g., blood pressure).
As a surgeon you would never go to the operating room not knowing the “rules of surgery.” Do not go to the office without knowing the pertinent aspects of coding. You are judged on what you should know not what you currently know!
