JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
JSI RESEARCH AND TRAINING INST
Speaker: Lissa Singer, MBA, RNP, CPC-I
Introduction to Coding and Documentation for STD Services
August 7, 2013
Lissa Singer:
Good Morning or Good afternoon to everyone out there depending on what coast you’re on. I really am thrilled to be here today to talk to you about coding for STI services.
We do have a few learning objectives for today’s presentation. I hope you all walk away with a basic understanding of ICD-9 or International Classification of Disease or Diagnoses coding. I hope you walk away with an understanding coding for evaluation and management visits which is the bulk of what you do. I hope you understand coding for basic office procedures with the use of modifiers.
The next slide just talks about the fact that I am going to give you a lot of great information today but your billing and coding decisions are your own.
When we talk about coding its necessary to think about coding in the perspective of what’s medically necessary to do. Where do you turn to for a good definition of medical necessity of course Medicare and Medicaid has a good definition and I am going to just read it to you: “A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the function of a malformed body member.”
Hopefully you don’t see a lot of that in your service. It’s generally considered to be a service consistent with the symptoms or diagnosis; Consistent with what is generally accepted in terms of medical standards; Not done for the convenience of patient or provider – it other words let’s just get everything done today because just it’s easier; Needs to be rendered at the most appropriate level.
I am going to give you a lot of great information today. You are going to be able to document for very high level services. The most important thing is the questions that you ask and the exam that you do and the prescriptions or the treatments that you do are considered medically necessary and rendered at the most appropriate level.
Everyone always asks me at the end of a presentation am I ever going to go to jail. I can tell you I have been doing this for quite a long time and no one I have ever known has ever gone to jail for over-coding or under coding or fraud or abuse. But it is important that you know the definitions or fraud and abuse. The worst thing that could ever probably happen to you is you would have to pay back some fines but you won’t go to jail. The government has great definitions for fraud and abuse.
Over coding is billing for high or more complex services than was actually rendered. That is considered fraud.
On the flipside, under coding is also considered fraud. And again that just goes back to Medicare and because Medicare clients have to pay a co-pay based on the cost of their visit and if you under code they can actually afford to come back more frequently which encourages frequent fliers. Unfortunately, you don’t get your money back if you’re under coding – they also consider that just a little bit fraudulent as well. Waving a co-pay for commercial insurances and Medicare and Medicaid is also considered fraud. They consider it your responsibility to collect the co-pay and their responsibility is to pay you the remainder of the visit. However if you do have a policy for financial need you can use that to wave a co-pay on an occasional basis. And then the last is falsely establishing medical necessity. This is considered reporting false or inaccurate diagnosis codes. That is considered abuse.
Before I actually get into the talk about coding let’s talk a little bit about how you might be credentialed with the payer. There is a type of billing called incident to billing Incident to billing is considered billing as if the supervising provider was the provider who saw the patient. So allied health professional bills as if the medical director or physician who is in the practice saw the patients himself. I need to just tell you this sounds great because you only have to credential 1 or 2 people. But there are multiple limitations when you do this type of billing. You can’t see any new patients or any established patients with new problems. And for most payers the doctor needs to be directly onsite if you use this time of billing. Medicaid and Medicare and many of the commercial insurances do enroll Allied Health professions: PA, NPs so I would consider you to consider both sides of the coin when thinking about how you’re going to credential your providers. Also know that when you individually credential your PA’s and NP’s you will take a slight decrease in pay – 10-20% depending on who the payer is.
Let’s move on to the basics about coding. There are a couple of basics like “who,” “what” “why” “where” and “when.” The first is your ICD-9 Codes or your International classification of disease codes. Those are your diagnosis codes. That’s why you did what you did. Your CPT codes or your current procedure terminology codes are your “what.”Modifiers are the exception to the rule and they are “the additional info.” You also have HCPCS codes or Health Care Common Procedure codes – they are the “what else.”
Let’s talk about ICD-9 codes. They are the why or what you do. They are alpha-numeric. They are 3-5 characters long with a decimal point in there somewhere. It’s important to have the most current ICD-9 codes because if you’re off by just one digit your claim can be denied because they don’t recognize the ICD-9 code. When you get an ICD-9 book, usually it’s divided into two volumes – volume 2 and volume 1. It’s very important that you look up in volume 2 the diagnosis that you are looking for. So if it’s vaginal discharge, chlamydia, gonorrhea, you look it up in volume 2 in the alphabetical index and it will immediately give you an ICD-9 code. But then I caution you – then look up the ICD-9 in the index in the front of the book and that will give you much more information about the ICD-9 code that you are about to select. There are some codes that begin with the letter V and I will tell you to use these as a last resort.
When you look up your ICD-9 codes it’s very important to use the most specific code available. It’s very common for people to use cheat sheets. You’re not doing the full range of family planning or family practice so your diagnosis codes are going to strictly be around sexually transmitted infections. Most of them will fit on one page – maybe half a page so you will have them available to you. Use a cheat sheet and definitely update it every year because there are changes. These ICD-9 codes are not just used for reimbursement they are used all over the world to classify diseases and to see how many people in the United States have hypertension or gonorrhea – so important for statistics as well. Just as you are getting used to ICD-9, get ready for ICD-10 which is available in October 2014. It is a much better coding system. You will find it a much more detailed coding system.
There are seven ICD-9 usage guidelines and they will remain the same for ICD-10. It very important to identify all the diagnosis, symptoms and conditions and link them appropriately. Any diagnosis, symptom or condition affects your treatment plan that day definitely code it.
List the primary condition first. That is the one you perceive as most important that day. Definitely utilize all five digits if possible and be as specific as possible. Probable, suspected, rule out, diagnosis should not be coded. It’s okay to put in notes. Don’t code unless you are absolutely sure.
You can code chronic diseases as many times as the patient receives treatment. Code diagnosis for which service is performed; if the diagnosis is different after service list new diagnosis only. This is generally for biopsies -- wait for pathology report to come back so you can use most appropriate diagnosis code. And the last of the usage guidelines is do not code what no longer exists and I will tell you there is one caveat for that. When your patients come back for a rescreening you still can use whatever you are screening them for because at the time you are doing the visit you don’t know if they still have it or they have been infected.
The next couple of slides are ICD-9 examples. They are just for your reference – things that you might want to put on your cheat sheet.
What happens when you don’t have a diagnosis or the patients have no symptoms? Here you will be forced to use a V code. Here are some V-code examples: V15. 85 is a personal history of contact with and suspected exposure to potentially hazardous body fluids -- so when the condom breaks you could use this code.
I will caution you to use the next V69.2 – high risk sexual behavior because your ICD-9 codes have a life longer than the claim. This diagnosis code made actually label the patient so use this with caution. Some special screening codes are available to you in this slide and in the next slide is just a number of V codes that is available for your reference.
Okay, so let’s talk about the meat of what you do and that’s the current procedural terminology (CPT) codes. That’s the “what.” They are always going to be 5 numericcharacters in length. We are going to focus today mostly on evaluation and management. office visits, preventative visits and hospital visits are all considered evaluation and management codes. We are only going to talk about office visits today. And we are going to talk about some surgical procedures. In the surgical section the range is everything from cardiac bypass to wart removal – major to minor procedures.
So here is the CPT code range breakdown. 99201-99499 is where the Evaluation and Management codes live and it’s highlighted today because it’s where we are going to spend most of our time today. You have codes for anesthesia, surgery, radiology, pathology and medicine and that is the code break down as well.
There are some “what—else” codes and these are the healthcare common procedure codes. Again, these can be from 3-5 alpha-numeric characters in length. And here are some J codes that you might use if you’re paying for your own antibiotics and then giving them to patients at the visit. These are available for your reference and are current for 2013 and are treatments you might use for an STI clinic.
Let’s talk about ranking and linking. So when you see a patient and this is just an example. The example is a woman with pelvic pain and the diagnosis code is there for you. The woman has pelvic pain and condyloma today. This is ranked the providers perceived acuity. The pelvic pain is more concerning to the provider than the condyloma. The service that the provider provided was a 99214, a level 4 service. There is a 25 modifier there for a level 4 established patient. This provider saw this patient for both of these problems and then did minor surgical procedure which is destruction of the vulva lesion, which is the 56515 – but she only did this procedure for the condyloma, certainly not for the pelvic pain. No you would think that payers should be able to figure this out but they don’t. You have to be able to tell them that this is why I did this procedure and this is why I did this office visit. People can come up with a number of very creative ways to show the biller how you rank and link these together. But it is my opinion that the provider ought to do this because the person in the back office may not be a clinician and they need to know which is more important than the other. They might think the warts are more important.
Alright, here is the CDPT code range break. On the left hand side of the slide your new patient evaluation and management codes A level one is considered 99201, level 2 is considered 99202 and you can get the picture. The ones in red are the ones that I believe you in an STI clinic will use most frequently. Across from that is a range of reimbursements that you might see. If you look at 99201 versus 99211 -- that is your established patient level codes --is that the reimbursement are not the same for each level. So a high range for a 99201 might be $50 and a high range for a 99211 might be $30. Generally those hang in the 10-12-13 dollar range.
So why is that? They pay you more to see a new patient because if you’re a clinician you absolutely know that it is more difficult to see a new patient – you have to get a full history generally.
Your level of history, your level of exam and your level of decision making – each one of these are independently scored. They equal your level of service. Now the centers for Medicare and Medicaid came up with two sets of guidelines – one is 1995 and 1997 and they call them the “CMS 95 & 97 Guidelines.” We are going to focus on the 95 guidelines today because they are the easiest to understand. The reason that CMS did this is because there is not a lot of guidance for the code book. Even though CMS did this, these are the guidelines that every payer uses. Why reinvent the wheel? Even if you are not seeing a lot of Medicare patients these are the guidelines that most payers use.
It’s probably a very good idea to take out your handout. If you haven’t downloaded it yet, the next two slides are identical to your hand out. But what I am going to teach you now are the two rules about new patients and established patients. For a new patient, it something called the 3 of 3required. So a new patient office visit, your codes are on the left hand side, then your history is the second column – “exam.” “MDM” stands for “medical decision making” and then something called “time” in the last column. 99201 has a bunch of 1’s across for history, exam and medical decision making and for level 2 the same thing. Because each one of these elements is scored individually and then that equals the level of service. So for a new patient it’s called the “3 of 3 Rule” and that is the overall visit level is the lowest component score.
Let me just walk you through a number of examples. So the first example I am going to give you is the patient has a problem focused history. That is a level 1 history. So hopeful you find the level one right there. Then move to the exam column. This patient was well documented and has a detailed exam – so a level 3 exam. And there was low complexity medical decision making. So you have a level 1 history, a level 3 exam and medical decision making that is also of level 3. But you need 3 of 3 in order to build that particular level so you have to go to the lowest of the components. So in this particular case – a problem focused history, a detailed exam and low complexity decision making is a 99201.
Now I promised to talk to you about what all these other abbreviations are HPI, ROS. That’s coming. But what’s really important is that you learn the 3 of 3 rule and 2 of 3 rule which I will talk about next.
But let me just give one more example. For a new patient the next example is – take a look at the history column and we will go to a detailed history. So this person has a detailed history and a detailed exam, a level 3 exam with straight forward medical decision making. So we have a 3, 3, and a 2. And in this case it’s going to be a 99202.
Hopefully that is pretty clear to you. Let’s move on to established patients. But before I do let’s go back for 1 sec. I just want to talk about the definition of a new patient. A new patient is a patient that hasn’t had face to face service by a provider of the same specialty, within the group pack, within the same group practice, within the past 3 years. So what’s obvious is someone you have never seen before walks into your clinic as a new patient. But it could also be one that hasn’t been seen in three years. What’s also to note here is if you’re a large clinic agency and you have a number of satellites or sites all over the state or all over your city and you are using one tax ID to bill which most people do. If it’s a new patient, 5 days ago in one city or one location and then that patient goes to another satellite – it’s not a new patient anymore even though you have never seen that patient. Also, what also holds true is if a colleague of yours within the same clinic see’s that patient on day 10 and you see him on day 20 – it won’t be a new patient.