NP Office Coding

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NP Office Coding

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1. NP Office Coding On loan from: Allen Daugird, MD, MBA UNC Dept of Family Medicine May 2003

5. E & M Codes

6. What are “Evaluation and Management” Codes for office visits? Used for “cognitive services” -i.e. most of our office visits

7. History, PE, Medical Decision Making

8. What are the three major components of E&M services? Look at the grids (pp 2-3) at the front of your handouts These major components determine the level of the E&M CPT code

9. Patient who has never been seen in your office or the last time was longer than 3 years ago

10. What is a “new” patient? This is crucial in deciding which set of E&M codes to use Reimbursement higher for “new” codes

11. 35 minutes of total of 40 minutes of office visit for established patient used in counseling

12. What is a 99215 visit? When more than 50% of E&M visit is for face to face counseling or coordination of care, time can be the primary determinant of the code Have to document the time (note just like in the Jeopardy question) in the along with a description of the issues counseling was about See times in far right column of grids CANNOT use for MCR incident to billing

13. CPT Code for Brief HPI, 5 organ systems PE, moderate complexity decision making in an established patient

14. What is a 99214 office visit? Only need 2 of the 3 major components to support the E&M code level for established patients BUT need 3 of 3 for new patient codes

15. Freezing warts, injecting trigger points, excising moles

16. What are office procedures? Almost anything you do with your hands (vs. your brain) has a separate CPT code

17. Code for Ear Wax Removal

18. What is CPT code 69210? Almost anything you do with your hands (vs. your brain) has a separate CPT code Even though the office nurses usually do this, we can still bill for it (it is done “incident to” your services and under your supervision)

19. Code you use when providing both separately identifiable E&M service AND a procedure

20. What is Modifier “-25” at end of E&M code? you have to have documentation for both the E&M code and the procedure usually best if E&M services are for different diagnosis than procedure YOU must circle the “-25” modifier on the encounter form

21. Simple surgical procedures which do not have a global period and for which you DO charge for any post-op visits

22. What are “starred” procedures? See description at beginning of Surgery section of CPT book Can charge for separate E&M services if provided (use –25 modifier)

23. CPT Codes you would use for giving 100mg meperidine IM

24. What are 90782 AND J2175 When giving injections remember to charge for the supply of the drug itself (J codes)

25. ICD-9 Codes

26. What set of codes is used for diagnoses? International Classification of Diseases, 9th revision, Clinical Modification Adopted by HCFA, changes yearly Major new version in the works See primary care “short list” pp 5-6

27. Thousands and Thousands

28. How many ICD9 codes are there? The book is thick Organized by Organ System May start in index, but need to read the actual table for exclusions, etc You can find a diagnosis code for most everything by using the list on pp 5-6 (Available at www.aafp.org and updated annually in Oct)

29. Writing down “250” as shorthand for diabetes code “250.00”

30. What is inadequate diagnosis coding? Have to code ICD9 codes down to all available digits Codes can be 3, 4, or 5 digits

31. Diagnosis codes used for prevention, screening, contraception

32. What are “V” codes? Whole list of V codes to describe non-illness situations Many insurers will not pay for services when only these codes are used (including Medicare!)

33. Diagnosis you would use for patient with nausea but no vomiting when the cause is not yet clear

34. What is 787.02? There are a whole set of symptom ICD9 codes you can use when the diagnosis is not yet clear Very helpful in primary care for initial presenting complaints Beware of negative impact on patient’s insurability if you use disease diagnosis code (vs. symptom) that turns out to be wrong

35. CPT Codes 99381-99397

36. What are the prevention CPT codes? Age grouped codes Medicare will NOT pay for these (MCR HMO’s might) NC State Employees Health Plan: you must use these and V70.0 ICD9 code for the deductible to be waived Comprehensive Hx, Comp PE (< than in other E&M’s), counseling, lab

37. V70.0

38. What is the diagnosis code used for adult wellness exams? May also use v72.3 for gyn exam, v25.01 for oral contraception, etc Use V76.2 for MCR screening breast/pelvic exam (“special screening for malignant neoplasms, cervix”)

39. Daily Double Make a Wager

40. HealthCheck

41. What is the Well Child Check visit program for NC Medicaid? Medicaid has its own set of special codes and rules Rules are complex, and may want to consider using a special encounter form Reimbursement is excellent and worth the hassle

42. A Medicare patient who comes in with no medical problems and just wants a “physical”

43. What is an uncovered service under Medicare? Uncovered services do not need a waiver form signed, but you should discuss w/ the patient BEFORE providing services and see if they agree to pay themselves (pp 15-16) In reality this is unusual for most Medicare patients-they usually have some symptoms or illness (remember menopause, osteoarthritis, etc) MCR will pay for breast/pelvic exam q 2y

44. The CPT code type you would use for a woman coming in for a Pap, but who has new complaints of severe headaches and chest pain, which you evaluate & treat

45. What is an office visit E&M code Prevention codes do not cover significant medical problems You can use both a prevention code and E&M code with modifier 25, but usually an E&M code is used (would have to have documentation to support both)

46. A CPT code AND an ICD9 code

47. What are needed for every encounter form Insurance company computers will reject claims without both

48. An ICD9 Code that supports each CPT code

49. What is needed for every encounter form Insurance claims are submitted electronically It’s one computer talking to another A CPT code will not get paid unless there is a diagnosis code supporting it (i.e. the insurance computer has logic that will only pay for the CPT code if it finds certain ICD9 codes that it thinks justify it)

50. Billing for NP services under a physician name and provider ID

51. What is “incident to” billing? The way most commercial insurance is billed for NP services An option for MCR & MCD, but have to follow their rules for “incident to” (pp 10-13) NP’s can bill MCR/MCD directly, but will get only 85% of MCR fee

52. An E&M code physician/NP/CNM should never use

53. What is a 99211? This almost always is for nursing only visits Look at the grid for 99212: almost any clinician encounter will fulfill the criteria

54. CPT codes used for an established patient whom you evaluate for abdominal pain (Detailed Hx & PE) and also do anoscopy on

55. What are 99214-25 AND 46600? Need only 2 of 3 components for established patient E&M codes Use -25 modifier after CPT code to tell insurer you did E&M service separately in addition to procedure

56. Final Stumpers!

57. Final Stumpers Answer modifier “-51”

58. What modifier is used when multiple procedures are done on the same day

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