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B4: Crack the Code: Addressing Billing Code Issues Laura Brey, Training Director, NASBHC lbreynasbhc 919-866-0920 - PowerPoint PPT Presentation

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B4: Crack the Code: Addressing Billing Code Issues Laura Brey, Training Director, NASBHC [email protected] 919-866-0920. Welcome and Expectations. Objectives. The Participant will be able to Define CPT, ICD 9, and DSM 4 Coding

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B4: Crack the Code:

Addressing Billing Code Issues

Laura Brey, Training Director, NASBHC

[email protected]


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The Participant will be able to

  • DefineCPT, ICD 9, and DSM 4 Coding

  • Explainthe reasons why appropriate coding and documentation is so important in SBHC settings.

  • Demonstratecorrect use of CPT and ICD 9 codes

  • Explainthe rational for conducting routine medical record review and coding compliance audits in SBHC settings

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Coding Background and Terminology

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Coding Definition

  • Coding is an alphanumeric system used to translate medical procedures and services into data

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Types of Coding

  • Current Procedural Terminology (CPT)

  • International Classification of Diseases (ICD-9 Clinical Modification - CM)

  • Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)

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Coding is Medicare Drive

  • Pediatrics was not considered in original coding guidelines, so some of the things we do in SBHCs may not fit well

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SBHC Coding

  • There is no difference between coding in a SBHC and any other setting – the coding assumptions are the same.

  • You provide the same level of care regardless of the location.

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Why Code Correctly?

  • Reimbursement depends on it.

  • Codes describe the services you provide

  • Codes justify these services

  • Services not documented “never happened”

    PS: Never code for the purpose of getting more money

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The Coding Process has 2 Parts

1. “What you did” = CPT

2. “Why you did it” = ICD-9 or DSM-4 TR


a what and a why


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When a provider is under-coding they tell the wrong story

This wrong story is:

  • SBHC Providers are seeing very few patients with multiple problems.

  • SBHC Providers should see more patients since they are not seeing complicated patients.

  • The SBHC should decrease the number of physicians and add more mid-level providers.

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There Are Two Coding Guidelines - 1995 & 1997

  • Both 1995 and 1997 guidelines are approved for use by CMS

  • Agencies may specify use of 1995 or 1997 guidelines

  • 1997 guidelines are more specific than 1995 in the examination portion (they are more computer friendly)

  • New guidelines have been proposed, but have not yet been accepted

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Coding Guidelines 1995 vs. 1997

This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version.


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  • Intentional deception or misrepresentation

    • Deliberately billing for services not performed

    • Unbundling of services

    • Intentionally submitting duplicate claims

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  • Improper billing practices

    • Billing for non-covered services

    • Misusing codes on a claim form

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Accept it, you will make them.

Your best defense is having a plan for your coding and being able to explain it.


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Over-coding and Under-coding

  • CPT and ICD-9 codes must always relate

  • The first ICD-9 code you use drives the relationship to the CPT code

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CPT Codes document:

  • Level of Service

  • Procedures Provided

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Examples of CPT codes

Evaluation & Management















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ICD-9 and DSM4 Codes document:

The reason behind the visit

(They must support the CPT codes)

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General Coding Principles

  • Coding gets you paid for your services

  • Coding can be used to justify the need for services to your funders

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Coding with ICD-9

  • ICD-9 codes have 3, 4 or 5 digits

    • The greater the number of digits, the higher the specificity

      • Use a 5-digit code when it exists

      • Use a 4-digit code only if there is no 5-digit code with the same category

      • Use a 3-digit code only if there is no 4-digit code within the same category

        PS: Omitting the required 4th or 5th digit will result in the denial of a claim. Do not add any additional digits, even zero

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ICD-9-CM Codes

Range from 001.0 to V82.9

  • They identify:

    • Diagnoses

    • Symptoms

    • Conditions

    • Problems

    • Complaints

    • Other reason for the procedure, service, or supply provided

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ICD-9-CM Codes

  • Three volumes

    • Volume 1 Tabular List of Diseases

      • Notes all exclusive terms and 5th-digit instructions

    • Volume 2 Alphabetic Index of Diseases

      • Does not contain detail – Do Not code from this volume

    • Volume 3 Procedures

      • Used almost exclusively for hospital services

        PS: (All 3 Volumes are generally found in one binding)

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“V” Codes

  • For circumstances other than disease or injury

  • Three categories:

    • Problem – Could affect overall health status, but is not a current illness or injury

      • Ex.: V14.2 Personal history of allergy to sulfonamines

    • Service – Circumstances other than illness or injury

      • Ex.: V68.1 Issue of a repeat prescription

    • Factual – Certain facts that do not fall into the “problem” or “service” categories

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“V” Codes

  • Can be used as a:

    • Solo Code

    • Principal code

    • Secondary code

  • May represent check-ups, screenings, administrative requests, prescription refills

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Rules for Coding Outpatient Visits

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Determine Type of Office Visit

  • Evaluation and Management

    New Patients vs. Established Patients

  • Preventive Health Visits

    New Patients vs. Established Patients

  • Counseling Visits

    Medical Visit – talker only

  • Mental Health Visits

    New Patients vs. Established Patients

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Determine Medical Necessity

  • Services are reasonable and necessary for the diagnosis and treatment of illness or injury.

  • All payors define necessity differently

  • Clinical rationale must be documented through coding.

  • You cannot write more, to get paid more.

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Determine Chief Complaint

  • The reason for the patient’s visit

    • S of a SOAP note

  • Codes used must relate to chief complaint or they are invalid

  • And, the chief complaint must be documented in the chart

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Evaluation/Management (E / M) Services

  • Used for acute care visits

  • Five levels of service

  • Seven components within the levels

    • Key components – history, exam and medical decision making

    • Contributory components – counseling, coordination of care, nature of presenting problem, and time

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Evaluation/Management (E / M) Services

  • Beginning information about coding deals with the three key components:

    • History

    • Examination

    • Medical Decision Making

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Evaluation/Management (E / M) Services

There are 5 Levels of service

  • Minimal

  • Self-Limited or Minor

  • Low Severity

  • Moderate Severity

  • High Severity

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New Patients

Level 1 99201

Level 2 99202

Level 3 99203

Level 4 99204

Level 5 99205

Established Patients






CPT Codes Used for E/M Visits

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Coding Steps

  • First Step- Determine if your patient is:

    A New Patient


    An Established Patient

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Definition of a new patient:

  • It is the patient’s first visit to the provider

  • The patient has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.

    PS: Any time a patient is seen in an Emergency Room they are considered a new patient

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If your patient does not meet the definition of a New Patient, then they are an Established Patient

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Coding Steps

  • Second Step - determine the level of service for the visit,

    To do this you need to determine the level of service for each key component separately

    There are 3 key components

    They are:

    1. History (HPI, ROS, PFSH)

    2. Examination

    3. Medical Decision Making

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Coding Steps

New Patients

  • Within the 3 key components, there are 5 levels of service

  • Remember to Consider the Key Components separately:

    • HPI, ROS, PFSH

    • Examination

    • Medical Decision Making

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Example - New PatientThe Level of Service for a new patient visit is determined by the lowest level of service (1 through 5) of the three key components

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Coding Steps

Established Patients

  • Again Consider the Key Components Separately:

    • HPI, ROS, PFSH

    • Examination

    • Medical Decision Making

  • The level of service (1 – 5) is determined by the level that appears in 2 of the three components, or by the middle level

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How to Steps of Coding: Determine Level of Medical Decision MakingDetermine Level of History ComponentDetermine Level of Physical Examination(You will need to reference the chart – examination notes for this)

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Determine Level of Medical Decision Making

  • Medical Decision Making consists of three sections:

    • Diagnosis or Management Problems

    • Diagnostic Procedures

    • Treatment of Management Options

  • Level is determined by the level found in two of the three categories – or the middle number if all three are different

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Determine Level of Medical Decision Making Section I: Diagnosis or Management of Problems

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Determine Level of Medical Decision Making Section II: Diagnostic Procedures

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Determine Level of Medical Decision Making Section III: Treatment or Management Options

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How to Steps of Coding: Determine Level of History Component

  • History component consists of three sections:

    • History of Present Illness (HPI)

    • Review of Systems (ROS)

    • Patient, Family, and Social History (PFSH)

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Determine Level of History ComponentSection I: History of Present Illness

  • Location

  • Quality

  • Severity

  • Duration

  • Timing

  • Context

  • Modifying factors

  • Associated signs and symptoms

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Determine Level of History ComponentSection II: Review of Systems

  • Constitutional symptoms (fever, wt loss, etc.)

  • Eyes

  • Ears, nose, mouth, throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurologic

  • Psychiatric

  • Endocrine

  • Hematologic/lymphatic

  • Allergic/immunologic

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Determine Level of History ComponentSection III: Patient, Family and Social History

  • Past medical history

    • Medication allergies

  • Patient’s family history

  • Patient’s social history

    • Age-appropriate review of past and current activities

      • Tobacco usage

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History Component Matrix(Number of components of each HPI, ROS & PFSH required for each level)

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How to of Coding Steps: Determine Level of Physical Examination

  • Constitutional

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskletal

  • Skin

  • Neurologic

  • Psychiatric

  • Hematologic/Lympatic/Immunologic

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Determine Level of Physical Examination:# of body systems required for each level

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Coding Exercise for Evaluation/ Management Services

Suzy Q is a 16 y/o female with c/o

severe “female” cramps - worse than usual.

She states she took Midol and it only

helped a little. She is a new patient.

Document on the exam and encounter

form to a level 3, using audit sheet

as reference.

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Count the components support level 3

HRI 1 - Midol

ROS 1 - cramps

PFSH - 0


Level 3

Exam 1-const





Level 3

Med Decision

- acute/uncomp

- OTCs


Level 3

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Counseling /Education Only support level 3During and E and M Visit

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New support level 3Patients

10 minutes 99201

20 minutes 99202

30 minutes 99203

45 minutes 99204

60 minutes 99205

Established Patients

5 minutes 99211

10 minutes 99212

15 minutes 99213

25 minutes 99214

40 minutes 99215

CPT Codes Used for Counseling/Education Only E and M Visits

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Preventive Services support level 3

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Preventive Services support level 3

  • These visits include a comprehensive history and examination, as well as appropriate counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of age-appropriate laboratory/diagnostic procedures.

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Preventive Services support level 3

  • “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination.

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Preventive Service Codes support level 3

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Preventive Services support level 3

Appropriate ICD-9 codes would be:

  • V20.2 for a Routine Infant or Child Health Check

  • V70.3 for a Sports Physical

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Preventive Services support level 3

  • Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately:

    • Examples:

      • Snellen Test

      • Laboratory

      • Immunizations

      • Administration of Immunizations

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A provider should know what services are covered. support level 3

Services must be documented and medically necessaryin order for payment to be made.

Do you, as a provider, know if all services provided are covered?

Are you documenting properly, and what about this “medically necessary” bit?

Coverage Issues

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How Much are you Paid? support level 3

  • Reimbursement

    • Reductions in reimbursement rates by provider type

      • Physician - not discounted

      • NP or PA - sometimes discounted

      • Clinical Psychologist - discounted

      • LCSW - further discounted

      • Other - discounted if covered

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Reimbursement Issues support level 3

  • E&M codes are limited to physicians, PAs, NPs, nurses

  • Same is true for 90805, 90807, 90809 codes

  • An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs

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Documentation and Coding: support level 3Fraud and Abuse

  • Services MUST be medically necessary (determined by payers based on a review of services billed)

  • Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.

  • Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider

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Elements of “Incident To” support level 3

  • An integral part of the physician’s professional service

  • Commonly rendered without charge or generally not itemized separately in the physician’s bill

  • Of a type that are commonly furnished in physician’s office or clinic

  • Furnished under the physician’s direct personal supervision

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Common Pitfalls in support level 3Coding

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About Time With the Patient support level 3

  • Do not base your level of service on time spent with patient.

  • Time only comes into play if you are billing for counseling within an acute visit or if all you are doing is counseling

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Sports Physicals support level 3

  • They are not meant to be comprehensive physicals – their focus is different

  • Check www.aap.orgfor an appropriate form

  • You can bill for a complete PE and a sports PE within the same year

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Counseling Visits support level 3

Counseling visits are when client comes in to discuss a problem only. No hands are laid on the patient.

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Example support level 3Dietary Surveillance & Counseling

There must be a dietary problem in order to justify this code.

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Coding Compliance Audit support level 3

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Questions & Answers support level 3