CPT CODING
FOR YOUR
MEDICAL
HOME
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CPT FOR THE MEDICAL HOME
MEDICAL HOME
Julian’s mom brings him complaining that he is
tugging on his right ear.
After an examination you diagnose him with an
acute otitis media and discuss treatment
MEDICAL HOME
Erica admits to you she has had an alcohol problem
for the last 6 months.
You help her find the appropriate care Is this a medical home?
MEDICAL HOME
During your lunch break you take a
phone call from the pediatric
gastroenterologist about your mutual
patient Jeffrey. The GI doctor wants him to see an ENT and you agree
to take care of this
MEDICAL HOME
The answer to all these questions is a
resounding YES.
The pediatrician’s office has always been
a medical home. We invented it years ago!
CPT FOR THE MEDICAL HOME
The AAP gave birth to the medical home
as Pediatricians we have coordinated care for our
patients
So what is Patient Centered Medical Home? it is the same thing but now with Internists and
Family Practitioners embracing the concept, it has a fancy name
CPT FOR THE MEDICAL HOME
PATIENT CENTERED MEDICAL HOME
doing more for your patients than you did
before to keep them in you home
face-to-face visits
evaluation and treatment of ADHD treatment of warts
minor surgery
non-face-to-face visits care coordination
CPT FOR THE MEDICAL HOME
So how do I code for what I do in the
What is coding and why is it
important to me?
Coding is how you will
make your living
It tells the insurers and
auditors what the patient’s
problems were and what
you did for them
Increase Reimbursement and
Decrease Liability Through
Physician Knowledge and Use of
Coding
Increase revenues by
increasing productivity
without working harder !
CPT FOR THE MEDICAL HOME
Basic CPT coding remains the same
Learn the CPT codes as you coordinate
care for your patients
Medical Team coding
Physician and Non-Physician Prolonged services coding
Well visit codes
Very simple
Only need to know if patient is
“old” or “new” and the age
New patient – one not seen by
Well visit Codes –
New Patients
99381 – under 1 year
99382 – 1 - 4 years
99383 – 5 - 11 years
99384 – 12 - 17 years
99385 – 18 – 39 years
Well Visit Codes –
Established Patients
99391 – under 1 year
99392 – 1 – 4 years
99393 – 5 – 11 years
99394 – 12 – 17 years
99395 – 18 – 39 years
Evaluation and
Management
Codes
Routine sick visits
Based on severity of illness
and work done
If more than 50% of visit is
counseling, then time is an
element
E/M Codes
New patient codes require all 3 elements 99201-5
Established patients only require 2 out of 3 elements 99211-5
Office Visits – New Patient
Codes 99201 99202 99203 99204 99205 History Problem Focused Expande d Problem Focused Detailed Compre hensive Compre hensive Exam Problem Focused Expande d Problem Focused Detailed Compre hensive Compre hensive Decision Making Straight forward Straight forward Low complex Moderat e complex High complex Time FF 10 20 30 45 60 Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3Codes 99211 99212 99213 99214 99215 History Not Required Problem Focused Expande d Problem Focused Detailed Compre hensive Require d Element s HPI 1-3 ROS N/A PFSH N/A HPI 1-3 ROS 1 PFSH N/A HPI 4+ ROS 2-9 PFSH 1/3 HPI 4+ ROS 10+ PFSH 2/3 Exam Not Required Problem Focused Expande d Problem Focused Detailed Compre hensive Require d Element s 1 Area 2-4 Areas 5-7 Areas >8 Areas
CPT FOR THE MEDICAL HOME
Perhaps as a PCMH you will be providing
more services to you patients, i.e.
PROCEDURES
INTEGUMENTARY SYSTEM 10040 ACNE SURGERY 10060 I&D OF ABSCESS
10061 COMPLICATED OR MULTIPLE 10120 I&D FOREIGH BODY SUBQ
PROCEDURES
16000 INITIAL TREATMENT FIRST DEGREE
BURN-LOCAL TREATMENT
16010-30 DRESSING AND/OR DEBRIDEMENT
WITH/WITHOUT ANESTHESIA SMALL TO LARGE
17000-4 DESTRUCTION(ACTINIC) 17110-11 DESTRUCTION WARTS
PROCEDURES
26641 CLOSED TREATMENT OF CARPOMETACARPAL
DISLOCATION THUMB WITH MANIPULATION
26670 NOT THUMB
26720 CLOSED TREATMENT OF PHALANGEAL SHAFT
PROCEDURES
30300 REMOVAL FB INTRANASAL 94150 NEWBORN CIRCUMCISION
54162 LYSIS OF PENILE POSTCIRC ADHESIONS
54450 FORESKIN MANIPULATION INCLUDING LYSIS
PROCEDURES
99173 SCREENING VISUAL ACUITY 94150 VITAL CAPACITY
94640 INHALATION TREATMENT FOR ACUTE AIRWAY
OBSTRUCTION
94664 DEMO OR EVALUATION OF PTUSE OF
NEBULIZER OR MDI
WELL AND SICK VISITS
3 y/o Joey comes in for her well visit. She
is wheezing and has subcostal retractions
What do you do?
a. cancel the well visit and treat the
asthma
b. do both well and sick visits c. send her to the hospital d. check her insurance
WELL AND SICK VISITS
d. check insurance first If the insurance company will not pay you
for both visits you have a decision to make-
a. do both visits and lose money
b. perform the well visit and send her to
the ER
c. treat the asthma and have the family
WELL AND SICK VISITS
There is no “right” answer Personally I think that none of us should choose to
lose money because the patient’s insurance won’t pay for both visits.
The patient’s have chosen their insurance and they
have to learn to live with the affects of their decisions
CPT FOR THE MEDICAL HOME
Erica has come into the office wheezing. Here are
your findings:
cc, hpi-5 items, ph, fh, ros-3, physical exam
includes 7 systems
You give Erica a pulmonary function test and based
on that a nebulizer treatment with Xopenx.
You then code the visit as 99214, 94010 and 94640
CPT FOR THE MEDICAL HOME
Let’s say that Erica needed a second nebulizer
treatment. You would then notate the 94640 and repeat it with the modifier 76 after it. This tells the MCO that the same physician, on the same day performed the same procedure on the same
CPT FOR THE MEDICAL HOME
Let’s change the scenario again. You send Erica
home after the first nebulizer treatment. You too go home. Erica gets worse, returns to the office where one of your associates evaluates her and repeats the nebulizer.
You now code the visit as
99214, 94640, 94640-76, 94010 a. True
CPT FOR THE MEDICAL HOME
b. false
The repeat 94640 should not have the 76 modifier
as it wasn’t the same doctor.
The 77 modifier is for the same patient, the same
day, the same procedure repeated but by another doctor.
So with the 77 modifier we are okay a. true b. false
CPT FOR THE MEDICAL HOME
b. false
Everything is okay except for the 99214. With the
extra work provided by the second doctor in the afternoon you could now use 99215 and get paid more money!
MODIFIERS
SOMETHING DIFFERENT WAS DONE -25
SIGNIFICANT, SEPARATELY IDENTIFIABLE
E&M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR
OTHER SERVICE
NOT TO BE USED WHEN A DECISION IS
MODIFIERS
-63 PROCEDURE INFANT < 4KG -76
REPEAT PROCEDURE BY SAME PHYSICIAN,
SAME PT, SAME DAY
-77
REPEAT PROCEDURE BY DIFFERENT PHYSICIAN, SAME PT, SAME DAY
MODIFIERS
-50 BILATERAL PROCEDURES -51 MULTIPLE PROCEDURES -53 DISCONTINUED PROCEDURE -59 You have spent 70 minutes with Jeffrey and want to
be paid for your time.
a. 99215
b. 99215-25
c. 99215, 99354
CPT FOR THE MEDICAL HOME
a. 99215-you lost money (code for 40 min) b. 99215-25 why?
c. 99215, 99354
99354 prolonged face-face, 30-74 minutes
office or outpatient setting
99355 for each additional 30 minutes after
99354
CPT FOR THE MEDICAL HOME
IN THE PCMH THERE WILL BE TIMES WHEN
CPT FOR THE MEDICAL HOME
PROLONGED SERVICE WITHOUT PATIENT
CONTACT
may be reported on a different date i.e. record review
must relate to service where direct care
has or will occur
CPT FOR THE MEDICAL HOME
PROLONGED SERVICES WITHOUT DIRECT
PATIENT CONTACT
99358 30-60 minutes
99359 each additional 30 minutes
CPT FOR THE MEDICAL HOME
MEDICAL TEAM CONFERENCE
minimum 3 qualified healthcare
professionals
face-to-face evaluation must have
taken place within 60 days
time related to record keeping and
CPT FOR THE MEDICAL HOME
MEDICAL TEAM CONFERENCE, DIRECT
CONTACT WITH PATIENT &/or FAMILY
99366-30 minutes+ nonphysician
MEDIAL TEAM CONFERENCE, WITHOUT
DIRECT CONTACT
99367-30 minutes+ with physician 99368-nonphysician
CPT FOR THE MEDICAL HOME
CARE PLAN OVERSIGHT SERVICES
reported separately from the other
codes we have discussed
services within a 30 day period
only one physician may use this for a
given period of time-sole or predominant supervisory role
does not include low intensity or
CPT FOR THE MEDICAL HOME
CARE PLAN OVERSIGHT
99374-physician supervision of a patient
under care of home health agency, requiring physician development &/or revision of plans, patient status, etc
15-29 minutes per month 99375- 30 minutes or more
CPT FOR THE MEDICAL HOME
CARE PLAN OVERSIGHT
99377-supervision of hospice patient 15-29 minutes
99378-30 minutes or more
99279-supervision of nursing facility
patient 15-29 minutes
CPT FOR THE MEDICAL HOME
COUNSELING RISK FACTOR REDUCTION no specific illness present
diet and exercise substance abuse sexual practices injury prevention
CPT FOR THE MEDICAL HOME
PREVENTIVE MEDICINE, INDIVIDUAL
COUNSELING
99401 15 minutes 99402 30 minutes 99403 45 minutes 99404 60 minutes
CPT FOR THE MEDICAL HOME
BEHAVIORAL CHANGE INTERVENTIONS for behavior that is an illnesss
to change harmful behavior that has not
CPT FOR THE MEDICAL HOME
99406-tobacco cessation 3-10 minutes 99407 greater than 10 minutes
99408-alcohol &/or substance abuse
structured screening and intervention 15-30 minutes
CPT FOR THE MEDICAL HOME
GROUP COUNSELING
99078 for patients with symptoms or
established illness
99411 preventive counseling or risk factor reduction
CPT FOR THE MEDICAL HOME
NON-FACE-TO-FACE
Telephone physician to patient
cannot use if seen in next 24 hours cannot use if problem previously
addressed in last 7 days
Online and must be permanently stored once in 7 days for a particular service cannot be used if previous e&m service
CPT FOR THE MEDICAL HOME
TELEPHONE 99441 5-10 minutes 99442 11-20 minutes 99443 21-30 minutes ONLINE 99444CPT FOR THE MEDICAL HOME
Since you want to have a medical home
you also want to have a strong, and busy medical home
To help do this you will need to be able to
recall your patients for vaccines and well visits
RECALL OR NOT TO RECALL
ADVANTAGES BRING PATIENTS INTO THE OFFICE
Opportunity for annual examination CPT 99381-95
Opportunity to discuss health risks CPT 99401-4
Behavioral change interventions CPT 99406-9
RECALL OR NOT TO RECALL
I’m so busy now how can I see morepatients and why should I?
the why is easy,-it is to protect your
patients against the vaccine preventable diseases
RECALL OR NOT TO RECALL
Monetary advantages of bringing the patient infor a well examination
if you added one additional well visit per day
to your schedule and were paid $100.00 for that visit you would increase your revenue for a 50 week year by$25,000.00
if you used any screening tools (PHQ9) and or
the CPT codes 99401-9 (counseling/prevention) you could add an additional $7500.00
ADDITIONAL REVENUE
PROFIT ON THE VACCINE ITSELF 10-25% OVER ACQUISTION COST
PEDIATRICIANS SPEND $100,000/doc profit $10-25,000
ADDITIONAL REVENUE
VACCINE ADMINISTRATION FEES
PAID BY ALL MCO INCLUDING MEDICAID $10-30 per vaccine
2500 patients per doc
if you immunized 50% of your practice for
influenza the fees generated would be
$12,500-$37,500 for administration only this alone would pay for 1 fulltime staff
CPT FOR THE MEDICAL HOME
WHAT TO DO IF MANAGED CARE
ORGANIZATIONS WON’T ACCEPT THE CPT CODES?
renegotiate your contracts
demonstrates cost savings with the
medical home
demonstrate improved patient
CPT FOR THE MEDICAL HOME
How else can you increase what you get
paid for what you do?
NCQA Certification P4P Programs
CPT FOR THE MEDICAL HOME
What are category II CPT codes? There were developed to simplify
reporting of performance measures. These are directly related to Pay-for-Performance programs which if you
qualify for them, will put more money in your pocket for the same amount of work done.
CPT CATEGORY II
These codes describe the performance of a clinical
service. The regular CPT codes are also reported.
The codes are grouped within categories based on,
CPT CATEGORY II
The categories are:
Composite measures 0001F-0015F Patient management 0500F-0575F Patient history 1000F-1220F Physical exam 2000F-2050F Diagnostic screening 3006F-3573F
Therapeutic, preventive, other interventions 4000F-4306F
CPT CATEGORY II
Follow-up, other outcomes 5005F-5100F Patient safety 6005F-6045F Structural measures 7010F-7025F
CPT CATEGORY II
There are four different modifiers
1P-exclusion due to medical reasons 2P-exclusion due to patient choice
3P-exclusion due to system reason(not covered,
resources not available)
CPT CATEGORY II
An example courtesy of the AAP:
A patient presents as a follow-up for moderate,
persistent asthma on albuterol and inhaled steroids.
His history, physical exam and medical decision
which includes continuing his meds contribute to the CPT code of 99213 with the ICD-9 of 493.00
CPT CATEGORY II
You also report the following with the
493.00
1005F-persistent asthma 1038F-persistent asthma
4015F-persistent asthma, long-term
control medication prescribed
Since you participate in a P4P program
this documentation will support the extra money you now receive
CPT FOR THE MEDICAL HOME
Learn CPT and ICD-9 coding
Document your notes appropriately
Capture all your services on the superbill Review your EOBs to update your fee
schedules
Negotiate good contracts with the MCOs-don’t be afraid to drop your poor payors MAKE MONEY caring for your patients
The Truth:
”No Margin-No Mission”
• Physicians choose the best practices for quality care for children
• Then must use the coding and contracting systems to fund the services
• Those established services (such as vaccine delivery) that are undervalued may end