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(1)

CPT CODING

FOR YOUR

MEDICAL

HOME

(2)

Section on Administration and Practice

Management (SOAPM)

• “Home” to pediatricians interested or involved with the management or

administration of pediatric practices.

• Provides both basic and cutting edge administration and practice

management information to its members.

Benefits:

– SOAPM LISTSERV® discussions

– SOAPM’s newsletter soapmnews (bi-annual) – Pediatric Practice Managers Association – SOAPM NCE programs

• Open to all FAAPs, Resident Fellows, and eligible Affiliate Members with

an interest or active in practice management.

• Applications for Fellows and Affiliate Members are available on the AAP

(3)

CPT FOR THE MEDICAL HOME

(4)

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

(5)

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?

(6)

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

(7)

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!

(8)

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

(9)

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

(10)

CPT FOR THE MEDICAL HOME

 So how do I code for what I do in the

(11)

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

(12)

Increase Reimbursement and

Decrease Liability Through

Physician Knowledge and Use of

Coding

Increase revenues by

increasing productivity

without working harder !

(13)

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

(14)

Well visit codes

Very simple

Only need to know if patient is

“old” or “new” and the age

New patient – one not seen by

(15)

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

(16)

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

(17)

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

(18)

E/M Codes

 New patient codes require all 3 elements  99201-5

 Established patients only require 2 out of 3 elements  99211-5

(19)

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 3
(20)

Codes 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

(21)

CPT FOR THE MEDICAL HOME

 Perhaps as a PCMH you will be providing

more services to you patients, i.e.

(22)

PROCEDURES

 INTEGUMENTARY SYSTEM  10040 ACNE SURGERY  10060 I&D OF ABSCESS

 10061 COMPLICATED OR MULTIPLE  10120 I&D FOREIGH BODY SUBQ

(23)

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

(24)

PROCEDURES

 26641 CLOSED TREATMENT OF CARPOMETACARPAL

DISLOCATION THUMB WITH MANIPULATION

 26670 NOT THUMB

 26720 CLOSED TREATMENT OF PHALANGEAL SHAFT

(25)

PROCEDURES

 30300 REMOVAL FB INTRANASAL  94150 NEWBORN CIRCUMCISION

 54162 LYSIS OF PENILE POSTCIRC ADHESIONS

 54450 FORESKIN MANIPULATION INCLUDING LYSIS

(26)

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

(27)

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

(28)

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

(29)

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

(30)

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

(31)

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

(32)

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

(33)

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

(34)

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!

(35)

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

(36)

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

(37)

MODIFIERS

 -50  BILATERAL PROCEDURES  -51  MULTIPLE PROCEDURES  -53  DISCONTINUED PROCEDURE  -59
(38)

 You have spent 70 minutes with Jeffrey and want to

be paid for your time.

 a. 99215

 b. 99215-25

 c. 99215, 99354

(39)

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

(40)

CPT FOR THE MEDICAL HOME

 IN THE PCMH THERE WILL BE TIMES WHEN

(41)

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

(42)

CPT FOR THE MEDICAL HOME

 PROLONGED SERVICES WITHOUT DIRECT

PATIENT CONTACT

 99358 30-60 minutes

 99359 each additional 30 minutes

(43)

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

(44)

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

(45)

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

(46)

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

(47)

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

(48)

CPT FOR THE MEDICAL HOME

 COUNSELING RISK FACTOR REDUCTION  no specific illness present

 diet and exercise  substance abuse  sexual practices  injury prevention

(49)

CPT FOR THE MEDICAL HOME

 PREVENTIVE MEDICINE, INDIVIDUAL

COUNSELING

 99401 15 minutes  99402 30 minutes  99403 45 minutes  99404 60 minutes

(50)

CPT FOR THE MEDICAL HOME

 BEHAVIORAL CHANGE INTERVENTIONS  for behavior that is an illnesss

 to change harmful behavior that has not

(51)

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

(52)

CPT FOR THE MEDICAL HOME

 GROUP COUNSELING

 99078 for patients with symptoms or

established illness

99411 preventive counseling or risk factor reduction

(53)

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

(54)

CPT FOR THE MEDICAL HOME

 TELEPHONE  99441 5-10 minutes  99442 11-20 minutes  99443 21-30 minutes  ONLINE  99444
(55)

CPT 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

(56)

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

(57)

RECALL OR NOT TO RECALL

 I’m so busy now how can I see more

patients and why should I?

 the why is easy,-it is to protect your

patients against the vaccine preventable diseases

(58)

RECALL OR NOT TO RECALL

 Monetary advantages of bringing the patient in

for 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

(59)

ADDITIONAL REVENUE

 PROFIT ON THE VACCINE ITSELF

 10-25% OVER ACQUISTION COST

 PEDIATRICIANS SPEND $100,000/doc  profit $10-25,000

(60)

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

(61)

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

(62)

CPT FOR THE MEDICAL HOME

 How else can you increase what you get

paid for what you do?

 NCQA Certification  P4P Programs

(63)

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.

(64)

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,

(65)

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

(66)

CPT CATEGORY II

 Follow-up, other outcomes 5005F-5100F  Patient safety 6005F-6045F  Structural measures 7010F-7025F

(67)

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)

(68)

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

(69)

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

(70)

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

(71)

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

(72)

A DAY IN THE LIFE

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