Billing Basics

Ashley Busuttil M.D.

Part I
Billing Background

Learning Objectives
Definition of ICD-9 CM codes Definition of CPT codes Medical Necessity and the interplay between diagnosis and coding

Deciphering the Alphabet Soup

Diagnosis (ICD) versus Service (CPT)

ICD codes are diagnosis codes

Describe new and established diagnoses Also include symptom codes headache (symptom code), vs migraine (diagnosis code)

Diagnosis (ICD) versus Service (CPT)

CPT codes are service codes

Describe performed services, both procedures and evaluation/management (E/M) Service codes must be based on necessity determined by diagnosis/ICD-9 codes

ICD or Diagnosis/Disease Codes

International Classification of Diseases Developed by the WHO Facilitates classification of morbidity and mortality data and international disease standardization Revised periodically:
ICD-9 valid 1979-1998 ICD-10 valid 1999-Present

ICD-9 CM
ICD-9 CM: International Classification of Diseases, 9th Revision, Clinical Modification System modified from ICD, includes more specificity for clinical and billing purposes Revised annually ICD-10 CM currently under testing, may be in use in coming years.

ICD-9 CM Cont
ICD-9 CM diagnosis codes range from general to specific More specific codes may better support billing i.e. justify why higher level of service was deemed necessary
ICD-9 CM 427.9 427.31 250.01 Diagnosis Arrhythmia, NOS Atrial fibrillation Diabetes type I

250.03
595.0 590.10 428.1 428.30

Diabetes Type I, Uncontrolled

UTI -cystitis UTI pyelonephritis, acute CHF, left CHF, diastolic unspecified

V Codes (sub set of ICD-9 CM codes)

Code for preventative care Usually not reimbursable themselves, but May allow for reimbursement of other services not otherwise authorized
HIV, asymptomatic (v08) allows for payment of vaccines not otherwise reimbursed Family history, breast cancer (v16.3) allows for reimbursement of early screening or genetic testing

CPT Codes/Service Codes

Current Procedural Terminology Describe performed services, both procedures and Evaluation and Management (E/M) Service codes must be based on necessity determined by diagnosis/ICD-9 codes

CPT Codes Cont

Currently the national standard for almost all health insurers (Medicare, Medicaid and private insurers)
1960s 1970s 1983

Developed by AMA to standardize billing/coding for Surgical Specialties

Expanded to include medical procedures and services

Adopted and standardized by federal government to include all subspecialties

CPT Codes Cont

5 digit codes Cover all billable services and procedures
Anesthesia 00100-01999 Surgery 10040-69999 Radiology 70010-79999 Pathology and Laboratory 80001-89399 Medications (ie meds administered) 90700-99199 Evaluation and Management (E/M) 99201-99499

CPT Codes an example

An 65 yo man visits his PCP for his annual checkup and incidentally complains of 2 days of knee pain. On exam his knee is erythematous, warm, tender and swollen. You perform a joint aspiration, and he also receives a Pneumovax as part of his routine preventative care. 3 codes apply (and can all be used for the single visit)
Evaluation and management code Medication code (for vaccine) Surgery code (for joint aspiration)

Medical Necessity Rule

There must be a connection between the diagnosis and the corresponding service CPT code MD must decide what is medically necessary care for the given diagnosis, and bill accordingly Even if documentation is extensive, only bill for medically necessary care

Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statement

Medical necessity is determined based on the diagnosis submitted for that service or supply. Specificity and accuracy of diagnosis code and linkage on the claim form determine payment.

ICD-9CM and CPT

MAKE THE CONNECTION!!!

Part II
Using E&M Codes

Learning Objectives
The new versus established patient The three key components of the document
History Physical Exam Medical decision making

The New versus Established patient

E&M codes are broken down into inpatient vs outpatient Further divided into outpt new vs f/u and inpt new vs f/u

Level 1 2 3 4 5

Outpt New 99201 99202 99203 99204 99205

Outpt f/u 99211 99212 99213 99214 99215

Inpt New 99221 99222 99223

Inpt f/u 99231 99232 99233

The New versus Established Patient

A new patient has had no care by any member of the billing physicians specialty and practice group within 3 years.

The New versus Established patient Cont You work in a large multispecialty practice group. A gastroenterologist in your group, Dr. WW, follows a 50 yo man for IBD. Dr. WW refers him to you to establish primary care. The patient has never had a primary care MD before. New or established?

NEW

The New versus Established patient Cont

You come to your first continuity clinic on day 1 of your R2 year. You are dismayed to find 5 patients you have never seen before on your schedule, all intending to establish primary care. They all used to be primary care patients of your senior resident who just graduated and moved on to a grueling fellowship in pulmonary and critical care. New or established?

ESTABLISHED

The New versus Established patient Cont

You work in a small group practice in Beverly Hills. You just saw a 55 yo woman who came into establish new primary care. She used to see another doctor in your practice but she stopped seeing him when he was arrested for Medicare billing fraud 4 years ago. She has not had any medical care since. New or established?

NEW

3 Key Components of the Document

(follow along you your plastic card from here on)
(Chief Complaint) History (HPI, ROS, PMH/FH/SH) Physical Exam Medical Decision making (problems, data, risk) *First encounters - must meet criteria for all 3 components for a given billing level *Follow-up encounters - must meet criteria for only 2 of 3 components for a given billing level

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1 0 0 1 Level 3 99213 + 1 1 0 6 Level 4 99214 + 4 2 1 Level 5 99215 + 4 10 2

History HPI ROS PMH/FH/SH

Physical Exam

12 in >2 2 in each systems of 9 systems

Med Decision Making Problem N/A Data N/A Risk N/A

1 1

2 2

3 3

4 4

Minimal Low

Moderat High e

A Note on Level 1 billing for outpatient followups

Ignore itmostly pertains to nursing visits, focus on levels 2-5

Chief Complaint
Not considered one of the key components because does not determine which CPT code you can use but Required for EVERY level of billing, so ALWAYS include a chief complaint Chief complaint of follow-up is not sufficient Chief complaint of follow-up on diabetes is sufficient

History

Includes 3 components
HPI ROS PMH/FH/SH

HPI
Includes qualifiers that specifically refer to the chief complaint
Location Quality Duration Timing Severity Context Aggravating/Relieving factors Associated symptoms

HPI Cont
Refer to card
Brief = 1-3 qualifiers (levels 2-3) Extended = 4+ qualifiers (levels 4-5)

Eg. 65 yo man with cc of abdominal pain. Pain is severe, located in mid-epigastrum, radiates to back, is worsened by food. Also has a rash and urinary frequency. *Note that rash and urinary frequency may not count as HPI b/c dont refer to chief complaint abd pain.

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1-3 0 0 1 Level 3 99213 + 1-3 1 0 6 Level 4 99214 + 4 2 1 Level 5 99215 + 4 10 2

History HPI ROS PMH/FH/SH

Physical Exam

12 in >2 2 in each systems of 9 systems

Med Decision Making Problem N/A Data N/A Risk N/A

Minimal Low

Moderat High e

HPI Cont
Chronic Conditions
Because chronic medical conditions often do not have symptoms amenable to description through qualifiers, you can instead document the status of 3 chronic conditions in place of an extended (ie >/= 4 qualifiers) HPI Eg: A 72 yo male comes in with cc of f/u on hypertension, coronary artery disease and hypercholesterolemia. Documenting the status of each of these as improved, stable or worse can replace the HPI qualifiers

ROS
14 systems recognized by MediCare Constitutional Eyes Ears, Nose, Mouth Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neuro Skin and Breast Psych Heme/Lymph Endocrine Immuno/allergy

ROS Cont
Refer to your card
Problem Pertinent = 1 system (level 3) Extended = 2-9 systems (level 4) Complete = >/= 10 systems (level 5) * Medi-Cal requires 14 systems)

You may use a patient completed checklist for your ROS You must specifically document that you have reviewed the patient document, and state if it is an extended or complete ROS

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1 0 0 1 Level 3 99213 + 1 1 0 6 Level 4 99214 + 4 2-9 1 Level 5 99215 + 4 10 2

History HPI ROS PMH/FH/SH

Physical Exam

12 in >2 2 in each systems of 9 systems

Med Decision Making Problem N/A Data N/A Risk N/A

1 1

2 2

3 3

4 4

Minimal Low

Moderat High e

PMH/FH/SH
Past History includes:
Past Medical history Past Surgical History Medications Allergies Immunizations

Family History Social History

On a followup visit you may refer to a review of prior documentation of the past history Refer to your card - 1 components = level 4, 2 = level 5

Remember!!!
To meet a given billing level for the History key component, you must document at that level for EACH of the 3 subcomponents, HPI, ROS and PMH

Physical Exam
12 recognized organ systems for exam
Constitutional (includes vitals and general appearance) Eyes Ears, Nose, Mouth Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin and/or Breast/Chest Neurologic Psychiatric Hematologic/lymphatic

Note same as ROS but w/o immunologic or endocrine

Physical Exam Cont

Some additional tips on the PE
Extremities is not an organ system! LE edema is under CV JVP, carotid bruits are CV not neck EOMI is neuro, not eyes Gait and strength are part of MSK not neuro Orientation is psych, not neuro Medicare has a list of accepted elements of examination for each system (review card for details)

Physical Exam Cont

Refer to card
Problem focused = 1-5 elements (level 2) Problem expanded = 6+ elements (level 3) Detailed = 12 elements in >/= 2 systems (level 4) Comprehensive = 2 elements in 9 systems (level 5)

All inpatient H&P should qualify for as comprehensive

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1 0 0 1 Level 3 99213 + 1 1 0 6 Level 4 99214 + 4 2 1 Level 5 99215 + 4 10 2

History HPI ROS PMH/FH/SH

Physical Exam

12 in >2 2 in each systems of 9 systems

Med Decision Making Problem N/A Data N/A Risk N/A

1 1

2 2

3 3

4 4

Minimal Low

Moderat High e

Physical Exam Cont

Each documented element within a single organ system must be of a different method, ie looking vs palpation vs auscultation For eg: RRR no m/r/g is only one element within the CV system (auscultation only).
No m/r/g with non-displaced PMI is two elements (auscultation and palpation)

Physical Exam Cont

For Subspecialists Subspecialists have the option of documenting a detailed single system exam with multiple elements (think orthopedic exam of the knee)

Medical Decision Making

Includes 3 components
Number of Diagnoses/Problems Data Reviewed Risk of Conditions and Management

Diagnoses/Problems
Self limited/minor problem (2 max) = 1 point Established prob (stable/improved) = 1 point Established prob (worse) = 2 points New problem w/o planned w/u = 3 points New problem w/ planned w/u = 4 points *Billing level is based on point system; comprehensive/level 5 = 4 points * Remember to document new vs established problems and stability vs improvement/worsening

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1 0 0 1 Level 3 99213 + 1 1 0 6 Level 4 99214 + 4 2 1 Level 5 99215 + 4 10 2

History HPI ROS PMH/FH/SH

Physical Exam

12 in >2 2 in each systems of 9 systems

Med Decision Making Problem N/A Data N/A Risk N/A

1 1

2 2

3 3

4 4

Minimal Low

Moderat High e

Data Review
Complexity of data reviewed is determined by point system. Different types of data and different means of reviewing receive different points.

Data Review Cont

Lab test reviewed Radiology test reviewed Other diagnostic test reviewed
Independent review of radiology test/EKG etc

1 point 1 point 1 point

2 points

Review of test with performing MD Decision/attempt to obtain outside records Review and summary of outside records

1 point
1 point

1 point

Established Outpatient Visits

Level 1 99211 CC + N/A N/A N/A N/A Level 2 99212 + 1 0 0 1 Level 3 99213 + 1 1 0 6 Level 4 99214 + 4 2 1 12 in >2 systems Level 5 99215 + 4 10 2 2 in each of 9 systems

History HPI ROS PMH/FH/SH

Physical Exam

Med Decision Making Problem N/A Data N/A Risk N/A

1 1

2 2

3 3

4 4

Minimal Low

Moderate High

Risk
Determined by AMA guidelines re:
Severity of problem, Invasiveness of diagnostic procedures/ tests Risk of medications/treatments

Risk is determined by highest level in any one category

Risk Cont
Risk
Low

Problem
1 chronic stable problem 2 minor problems 1 acute non-systemic problem 2 stable chronic 1 new prob with unclear diagnosis 1 mild exacerbation Acute or chronic life threat prob Severe exac of chronic prob Acute AMS Psych risk to self

Data/Tests
ABG/PFT/UGI

Treatments
OTC meds PT/OT Minor surgery w/o RF IV medications Prescription rx Minor surg w/ RF Elective major surgery w/o RF Intense monitoring for drug toxicity (dig levels, heparin, coumadin) Elective surg w/ RF New DNR IV narcotics

Moderate

LP/thoracentesis Low risk cath Low risk endoscopy Excisional bx High risk cath High risk endoscopy EP test

High

Level of MDM
Determined by highest 2 of 3 MDM subcomponents (ie problem, data, risk) Note this is different than the History component when all 3 sub-components (HPI, ROS and PMH) must meet/exceed billing requirements

Level of MDM Cont

Problem 0-1 pts Data Risk Level MDM 0-1 pts Minimal 2 pts 2 pts Low 3 pts 3 pts 4 pts 4 pts

Moderate High Moderate High

Straight- Low forward

Other tips

Consultations
Consultation request must be documented by requesting physician The name of the requesting physician must be documented by the consulting physician There must be documentation of communication back to the requesting physician

Emergency and Critical Care

If you provide the equivalent of emergency or critical care you can bill as such
Pt presents to clinic with active chest pain who you stabilize with NTG, ASA and beta blockers and is then sent directly to ED Pt on the ward who develops an unstable tachyarrthymia who you cardiovert and otherwise stabilize prior to transfer to MICU

Attending Observation
Attending can use coding modifiers for outpatient visits that they supervise Attendings must directly supervise all patients in the following settings:
All new patients All patients seen by resident in first 6 months of training All patients billed >/= level 4

Counseling
If > 50% of patient encounter is spent with face to face counseling, you can bill for counseling time Total time with patient and percentage of time spent counseling must be documented