Jon Hathaway, MD PhD 4:00-5:00 pm Feb 1, Coding Made Easy. Coding for Cash And to avoid the penitentiary. Jon K. Hathaway, MD, PhD.

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Coding Made Easy

Coding for Cash

And to avoid the penitentiary

Jon K. Hathaway, MD, PhD

Objectives

Review Coding Documentation

Guidelines

Review the Global Package

Discuss ICD-9 and ICD-10

Review Inpatient coding (time

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coding level for E&M visits?

 I co de it .  Som eone  in m y ...  The  EMR  code s ...  I alw ays b ill ...  Othe r 0% 0% 0% 0% 0%

1.

I code it.

2.

Someone in my

office codes it.

3.

The EMR codes it.

4.

I always bill a

99213 (whatever

that is).

5.

Other

Purpose of Coding

To $tandardize the de$cription of

the patient’$ $ymptom or di$ea$e

proce$$.

To allow for retro$pective re$earch

to evaluate outcome$,

intervention$, etc.

To evaluate quality of care.

To evaluate what procedure$ are

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Types of Codes

ICD-9/10: Identifies

diseases or symptoms.

International

Classification of

Disease.

CPT-4: Identifies

procedures performed.

Current Procedural

Terminology.

ICD

ICD does not allow you to code for

“rule out”, “suspected” or “Probable”

conditions—indicate a symptom if

you don’t have a specific diagnosis.

Use only current conditions that are

the reason for the visit (if you don’t

treat or address the HTN or

(4)

coding (E&M)

Types of visits

– Problem visit

New

Established

(seen by practice or Dr in last 3 years)

– Consultation

– Preventative

New

Established

Age Ranges

What is the definition of

outpatient?

1.

Anyplace that isn’t

inpatient-duh!

2.

Only outpatient office

buildings not attached

to a hospital.

3.

Only private office

space, attachment to

hospital unimportant.

(5)

Elements of a Visit

History

Exam

Assessment

Plan

Elements of a Visit

History

– Chief Complaint

– History of Present Illness (HPI)

– Past Medical, Family and Social Hx (PSFH)

– Review of Systems (ROS)

Examination

– 1995 & 1997 guidelines

Medical Decision Making

– Number of Diagnoses

(6)

Elements of a Visit

History

– Chief Complaint (reason for the visit—doesn’t have to be a complaint) – HPI:  Elements – Location – Quality – Severity – Duration – Timing – Context – Modifying Factors

 2 types brief or extended.

– Brief has 1-3 elements – Extended has 4+ elements

– Extended can also be 3 chronic or inactive conditions.

Mrs. A c/o vaginal bleeding, heavy (could use pad count), lasting 5-7 days every 28 days for the last 6 months. Seem to be better when on OCP’s.

History

Level

HPI

ROS

PFSH

(7)

Elements of a Visit

ROS

– 12 areas: Constitutional, Eyes, ENT, CV,

Pulm, GI, GU, MS, Integumentary,

Neuro, Psych, Endo, Heme/lymph,

Allergy.

– One system: Expanded Problem

Focused

– 2-9 systems: Detailed

– 10+ systems: Comprehensive

Any problems with your bowels or

bladder?

Elements of a Visit

History

– PFSH (Past, Family, Social History)

(8)

History

Mrs. A c/o amenorrhea for 6

months, has been irregular since

age 18 when she gained a lot of

weight. Normal menses when on

OCP’s. Also c/o facial hair and a

“dirty neck”.

No Bowel or Bladder Issues

Past Medical History significant for

obesity and infertility despite

trying.

History

Level

HPI

ROS

PFSH

(9)

Moving On…

Exam

1995 Guidelines: Not good for basic

OB/GYN so fought for new

guidelines!!

(10)

Elements of an Exam

Constitutional:

– 3 vitals (BP, Pulse, Resp, Temp, Ht, Wt)

– General Appearance

GI:

– Exam of Abdomen (masses, tenderness)

– Exam of Liver and Spleen

– Occult blood (if indicated)

– Hernia

Elements of an Exam

GU

– Breast Exam

– Digital Rectal Exam

– External Genitalia

– Meatus: location, prolapse, lesions.

– Urethra: masses, tenderness, scarring.

– Bladder: fullness, masses, tenderness.

– Vagina: support, estrogen, discharge, lesions…

– Cervix: appearance, lesions, discharge

– Uterus: size, contour, mobility, position, support…

– Adnexa: mass, tenderness, organomegaly

(11)

Elements of an Exam

Neck:

– Thyroid – General Exam 

Respiratory

– Effort – Auscultation 

CV

– Auscultation

– Peripheral Vascular System (varicosities, swelling, pulses, edema, tenderness)

Lymphatic

– Palpation of lymph nodes: neck, axillae, &/or groin.

Skin

– Inspection and Palpation (rash, lesion, ulcer)

Neuro/Psych

– Orientation – Mood/Affect

Exam

Four Types

– Problem Focused: 1-5 elements

– Expanded PF: 6-11 elements

– Detailed: 12+ elements

(12)

Comprehensive Exam

All Consitutional: 3 vitals, general appearance.

All GI: Exam, liver/spleen, occult blood, hernia

Any 7 GU elements

One element from:

– Neck:  Thyroid  General Exam – Respiratory  Effort  Auscultation – CV  Auscultation

 Peripheral Vascular System (varicosities, swelling, pulses, edema, tenderness)

– Lymphatic

 Palpation of lymph nodes: neck, axillae, &/or groin.

– Skin

 Inspection and Palpation (rash, lesion, ulcer)

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1995 Guidelines

1 element

2-4 elements

5-7 elements

8+ elements

Problem Focused

Expanded PF

Detailed

Comprehensive

All of the following body parts get

bigger with age except?

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Here Comes the Hard Part

Medical Decision Making

– Straightforward

– Low Complexity

– Moderate Complexity

– High Complexity

– Number of Diagnoses or Management Options

– Amount or Complexity of Data to Review

– Risk of Complications or Morbidity/Mortality

Medical Decision Making

Diagnoses Minimal

Limited

Multiple

Extensive

Data

Minimal

Limited

Moderate

Extensive

Risk

Minimal

Low

Moderate

High

Straight

(15)

Number of Diagnoses

Self-Limited or Minor:

1 point

Established Problem, stable:

1 point

Established Problem, worsening:

2 points

New Problem, No additional w/u:

3 points

New Problem, additional w/u:

4 points

Minimal:

1 point

Limited:

2 points

Multiple:

3 points

Extensive:

4 points

Amount/Complexity of Data

 Review/Order lab tests or procedure: 1 point

– Radiology or Medical arena

 Discussion of diagnostic test results

w/ performing physician: 1 point

 Decision to obtain old records &/or

Obtaining history from someone other than patient: 2 points

 Review and summary of old records &/or

Obtaining history from someone other than patient &/or

Discussion of case with another provider: 2 points

 Independent visualization of image/tracing/specimen: 2 points

 Minimal: 1 point

 Limited: 2 points

 Multiple: 3 points

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Level of Risk

 Minimal: One self-limited or minor problem/CXR/superficial dressing. – Cold, insect bite, tinea corporis.

– UA, Wet Mount, blood tests, U/S ordered – Rest, Ace bandage

 Low: One stable chronic illness/superficial needle bx/OTC Rx. – Acute, uncomplicated illness or injury

– Arterial blood tests, Imaging studies with contrast (SIS) – Minor surgery with no identified risk factors, IV fluids

 Moderate: One or more chronic illnesses w/ mild exacerbation,

progression or side effects/diagnostic endoscopies w/ no identified risk factors.

– New problem with uncertain prognosis (breast lump), 2 stable chronic illness (DM and HTN), Acute illness w/ systemic sx, acute, complicated injury – Fetal STRESS test, CV imaging, Deep needle or incisional bx (including

culdocentesis

– Minor surgery with risk factors, Elective major surgery w/o risk factors, Management of prescription drugs, IV fluids with additives

 High: Acute or Chronic illnesses or injuries that pose a threat to life or

bodily function/diagnostic endoscopies w/ identified risk factors/Emergency major surgery.

– Abrupt change in neuro status

– CV imaging with risk factors, Dx endoscopies with risk factors

– Elective or emergency major surgery with risk factors, drug therapy requiring intensive monitoring for toxicity.

Minimal: One self-limited or minor

problem/CXR/superficial dressing.

– Wet Mount

– Rest

Low: One stable chronic illness/OTC Rx.

– Imaging studies with contrast (SIS)

– Minor surgery with no identified risk factors

– IV fluids

– Vaginitis

– Renewal of HRT/OCP

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 Moderate: One or more chronic illnesses w/ mild exacerbation,

progression or side effects/diagnostic endoscopies w/ no identified risk factors.

– New problem with uncertain prognosis (breast lump) – Irregular bleeding

– Diagnostic endoscopies w/ no identified risk factors – Minor surgery with risk factors

– Elective major surgery w/o risk factors – Management of prescription drugs – IV fluids with additives

 High: Acute or Chronic illnesses or injuries that pose a threat to

life or bodily function/diagnostic endoscopies w/ identified risk factors/Emergency major surgery.

– Dx endoscopies with risk factors – Pelvic Pain

– Multiple complaints

– Elective or emergency major surgery with risk factors – Drug therapy requiring intensive monitoring for toxicity.

Level of Risk

Medical Decision Making

– Number of Diagnoses or Management

Options

– Amount or Complexity of Data to

Review

– Risk of Complications or

Morbidity/Mortality

(18)

Medical Decision Making

Diagnoses Minimal

Limited

Multiple

Extensive

Data

Minimal

Limited

Moderate

Extensive

Risk

Minimal

Low

Moderate

High

Straight

Forward

Complexity

Low

Complexity

Moderate

Complexity

High

(19)

Putting it all together

New Patient

History

Exam

Medical Decision

Making

Level 1

Problem Focused Problem Focused Straight Forward

Level 2

Expanded Problem

Focused Expanded Problem Focused Straight Forward

Level 3

Detailed Detailed Low Complexity

Level 4

Comprehensive Comprehensive Moderate Complexity

Level 5

Comprehensive Comprehensive High Complexity

Putting it all together

Established Patient: Only Need 2 of 3!!

History

Exam

Medical Decision

Making

Level 1

Level 2

Problem Focused Problem Focused Straight Forward

Level 3

Expanded Problem Focused

Expanded Problem Focused

Low Complexity

Level 4

Detailed Detailed Moderate Complexity

(20)

Putting it all together

Initial Consultation

History

Exam

Medical Decision

Making

Level 1

Problem Focused Problem Focused Straight Forward

Level 2

Expanded Problem

Focused Expanded Problem Focused Straight Forward

Level 3

Detailed Detailed Low Complexity

Level 4

Comprehensive Comprehensive Moderate Complexity

Level 5

Comprehensive Comprehensive High Complexity

Putting it all together

Time-based Billing

New Patient Established Consultation

Level 1

10

5

15

Level 2

20

10

30

Level 3

30

15

40

(21)

Preventative Visits

Requirements based on age.

Payment for Hx and PE only (no MDM)

No specified elements of the exam.

– Must document a multisystem exam.

– For us includes breast and pelvic +/- Pap smear.

No need for CC or HPI.

Includes counseling such as contraception, safety,

need for screening tests, BSE, vaccines, etc.

Can bill for problem-based service if provided at

the same time (and documentation supports this).

– May not get paid though.

– ACOG suggests billing whichever takes the most time.

– Can also break up the visit into two visits.

– Patient may have a copay for E&M visit.

Most payers will not pay for 2 “annual exams” in

one year.

Medical Students

 Any contribution and participation of a student to the

performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable). You, the student, may document services in the medical record; however, the

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CHIEF COMPLAINT: Chronic pelvic pain. The patient is referred to Dr. X for an evaluation of her pelvic pain. HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 22-year-old Caucasian

female G zero whom I have been following in the clinic for several visits now

who has a history of longstanding chronic pelvic pain. Occurs most days and lasts all day. Stabbing mostly. Mainly located behind the symphysis pubis. No relief with voiding or BM. Non-cyclical. +dyspareunia.

ROS: No Bladder or Bowel problems except GERD.

PAST MEDICAL HISTORY: Significant for gastroesophageal reflux disease. PAST SURGICAL HISTORY: Tonsillectomy, adenoidectomy in 2007, as well as, diagnostic laparoscopy in 05/2008.

GYNECOLOGIC HISTORY: The patient does have a history of abnormal Pap smear in 04/2008 which I believe was a low grade squamous intraepithelial lesion. She followed up for colposcopy and had no procedures. Menarche onset at age 16, every 28 days lasting up to five days with moderate flow, however, associated with significant dysmenorrhea. The patient currently is on the Alesse birth control pills with continued cramping. The patient is sexually active. Has a positive history of Chlamydia and PID 01/2008.

SOCIAL HISTORY: Negativex3. She does have a boyfriend. Negative tobacco and illegal drugs. The patient admits to occasional social drinking a drink

approximately twice a month. FAMILY HISTORY: Noncontributory.

What is the History Level?

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PHYSICAL EXAMINATION: On examination 150 pounds, blood pressure 106/70, Pulse 72. GENERAL: NAD. No anxiety.

LUNGS: Clear to auscultation bilaterally.

CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, nontender, nondistended.

GENITOURINARY: External genitalia within normal limits. Vaginal wall, urethra and anus normal. Pelvic examination a small, anteverted, mobile uterus with normal adnexal examination. No acute tenderness to palpation.

The patient's hemoglobin in 05/2008 12.2 and hematocrit of 36. Last

gonorrhea, chlamydia cultures 10/10/2008 both negative. The patient did have an ultrasound done in 11/2008 at which point the uterus measures 6.7 x 3.4 x 4.7 cm, right and left ovaries within normal limits. The right ovary contained a simple cyst measuring 2.2 x 1.1 x 1.4 cm, left ovary was within normal limits. There was free fluid seen around both ovaries sounds.

What is the Physical Exam?

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ASSESSMENT/PLAN: The patient is a 22-year-old Caucasian female G0 with troubling psychiatric history, as well as, continued vague, fluctuating

complaints of pelvic pain, possibly component of a gastrointestinal trouble. I discussed with the patient expectant management versus

Depo-Provera. She would like to try depoprovera. I would like her to be evaluated by Dr. X. The patient was very open to the idea of seeing Dr. X. Given the findings on the ultrasound of fluid around the ovaries, a repeat ultrasound may be useful should she not improve here in the meantime. The

examination does not support an abscess or tubo-ovarian process at this point.

Medical Decision Making?

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What is the overall code?

Leve l 1 Le vel 2 Lev el 3 Lev el 4 Lev el 5 0% 0% 0% 0% 0%

1.

Level 1

2.

Level 2

3.

Level 3

4.

Level 4

5.

Level 5

Phew!!

So who really cares and can you get

away with a few incorrect codes?

I’m just too tired to worry about this

and so I just code a level 2 visit for

everything (this will cost you more

than $50K/year).

(27)

RVU differences

Established Patient

New Patient

99212 OUTPATIENT VISIT, RET 0.45 99213 OUTPATIENT VISIT, RET 0.67 99214 OUTPATIENT VISIT, RET 1.10 99215 OUT-PATIENT VISIT, RET 1.77 99201 OUT PATIENT VISIT NEW 0.45 99202 OUTPATIENT VISIT NEW 0.88 99203 OUTPATIENT VISIT NEW 1.34 99204 OUT-PATIENT VISIT NEW 2.00 99205 OUT PATIENT VISIT NEW 2.67

Rough estimate of Medicare RVU= $37. Private Insurance RVU= $60.

Besides humans, what other

animal has sex for pleasure

(28)

ICD-10

Was supposed to start October 1,

2013 but was pushed back to

October 1, 2014.

Many codes will have the same name

but there will be some differences—

especially for OB.

Currently a freeze on ICD-9 changes.

(29)

ICD-10

ICD-9

Molar Pregnancy:

– 630 Hydatidiform mole

Trophoblastic disease NOS Vesicular mole

ICD-10

Molar Pregnancy

– O01.0 Classical

hydatidiform mole

– O01.1 Incomplete and

partial hydatidiform

mole

– O01.9 Hydatidiform

mole, unspecified

ICD-10

ICD-9

631 Other abnormal

product of conception

Blighted ovum Mole: – NOS – carneous – fleshy – stone 

632 Missed abortion

Early fetal death before

completion of 22 weeks' gestation with retention of dead fetus

ICD-10

Other abnormal

products of conception

– O02.0 Blighted ovum and nonhydatidiform mole

Mole: carneous, fleshy,

intrauterine NOS, Pathological ovum – O02.1 Missed abortion

Incl.:Early fetal death

with retention of dead fetus

(30)

complications

 P02.4 Fetus and newborn affected

by prolapsed cord

 P02.5 Fetus and newborn affected

by other compression of umbilical cord

 P02.6 Fetus and newborn affected

by other and unspecified conditions of umbilical cord

complications.

Requires fifth digit; valid digits are in [brackets] under each code. See beginning of section 660-669 for definitions.

 663.0 Prolapse of cord [0,1,3]  663.1 Cord around neck, with

compression[0,1,3]

 663.2 Other and unspecified cord

entanglement, with compression [0,1,3]

 663.3 Other and unspecified cord

entanglement, without mention of compression [0,1,3]

 663.4 Short cord [0,1,3]  663.5 Vasa previa [0,1,3]  663.6 Vascular lesions of cord

[0,1,3]

 663.8 Other umbilical cord

complications [0,1,3]

 663.9 Unspecified umbilical cord

complication [0,1,3]

Polyp of female genital tract

ICD-9

621.0 Polyp of corpus uteri622.7 Mucous polyp of cervix219.0 Other benign neoplasm

of uterus : cervix uteri (adenomatous polyp of cervix)

623.7 Polyp of Vagina

624.6 Polyp of labia and vulva221 Benign neoplasm of other

female genital organs

(including adenomatous polyp and benign teratoma)

ICD-10

N84.0 Polyp of corpus uteri N84.1 Polyp of cervix uteri N84.2 Polyp of vagina N84.3 Polyp of vulva

N84.8 Polyp of other parts of

female genital tract

N84.9 Polyp of female genital

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My biggest fear about ICD-10 is:

 I will  have  to...  Incr ease d den i...  Will  need  to r.. .  Will  need

 to l...  Other

0% 0% 0% 0% 0% 1.

I will have to buy

new software.

2.

Increased denials.

3.

Will need to revise

billing sheets.

4.

Will need to learn

new codes.

5.

Other

HELP

Sources:

– Essential guide to Coding in OB/GYN

– OB/GYN Coding Manual

– FAQ for OB/GYN

(32)

Objectives

Review Coding Documentation

Guidelines

Figure

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References

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