Developmental Screening: Billing and Coding

1. Developmental Screening:Billing and Coding Michelle M. Macias, MD D-PIP Training Workshop June 16, 2006 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

2. Importance of Accurate Coding • Improved Information Processing • Accurate diagnostic coding requires analyzing all provided information (subjective and objective) • Decreased Liability • Documentation • Medico-legal • Compliance • Increased Reimbursement • One minute of extra work can result in an increased code level

3. Diagnostic Codes • International Classification of Diseases-Tenth Revision, Clinical Modification (ICD-10-CM) • Arranges diseases and injuries into groups according to established criteria • Numeric • Revised ~ q 10 years by WHO, annual updates by Health Care Financing Administration (HCFA) • U.S. still using ICD-9 codes, gradually implementing ICD-10

4. ICD-9 Codes • Code to the highest degree of specificity • Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results • Probable, suspected, questionable, or rule out should not be coded • List the ICD-9/10 code that is identified as the main reason for the service first, then list co-existing conditions • Chronic disease treated on an ongoing basis may be coded • Do not code for conditions previously tx that no longer exist

5. Developmental Coding: Examples • 783.42 Delayed milestones • 728.85 Hypertonia • 315.31 Language disorder, developmental • 315.9 Learning disorder, NOS • 348.3 Static encephalopathy

6. Current Procedural Terminology (CPT) • Published by the AMA • Listing of the codes and descriptions for procedures, services and supplies • Used to bill insurance carriers

7. CPT Coding5 Basic Principles of Use • Practitioner should select diagnosis and procedure codes • Document patient’s services to support codes (compliance) • Use separate codes for different encounters • Learn to use modifiers, testing and add-on codes • Design a superbill/computerized routing sheet

8. “RVU Review” • Resource Based Relative Value Scale (RBRVS) • Relative Value Units (RVUs): “The Coin of the Realm” • A numerical value (relative reimbursement) assigned to a CPT code • Calculated on • Amount of physician work • Practice expenses • Malpractice cost • Service location (office vs. hospital)

9. RVU Components of Physician Work • Pre-, intra-, post- service work • Time to perform the service • Technical skill and physical effort • Mental skill and judgment • Psychological stress associated with iatrogenic risk

10. RVUs  Cash • RVUs are assigned by the Relative Value Scale Update Committee (RUC) • Each 3rd party payer that uses RVus in payment calculations applies its own ‘conversion factor’ (CF) • The CF is multiplied by the RVU to determine that payor’s payment

11. TABLE 2CPT Codes for Developmental Screening

12. Developmental Screening • 96110: Developmental screening • Limited developmental testing, with interpretation and report • Expectation is that the screening tool will be completed by a non-physician staff member and reviewed by the physician • No physician work is included in the RVU • Reported in addition to E/M services provided on same date, with modifier (-25) • Report for eachscreen administered • Medicaid may not pay separately for developmental screening when provided as part of Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT)

13. Developmental Testing • 96111: Extended developmental testing/evaluation • Used for extended developmental testing typically provided by the medical provider • Includes the interpretation and report • Based on 1 hr of physician work • Reported in addition to E/M services provided on same date, with modifier

14. Evaluation and Management (E/M) Codes • Bill based on level of complexity- 3 major components • History • Physical Exam • Medical Decision Making (MDM) • Bill based on time • Only if counseling and coordination of care > 50% of visit

15. “Complexity” Billing: History

16. Examination • Problem Focused • Limited to affected body area or organ system • 1 body area/organ system • Expanded Problem Focused • Affected body are or organ system and other symptomatic or related organ system • 2-4 body areas/organ systems • Detailed • Extended exam of affected body area(s) and other symptomatic or related organ systems • 5-7 body areas /organ systems • Comprehensive • Complete single system specialty exam or • Complete multi-system exam • 8 or more body areas/organ systems

17. Medical Decision Making • Number of possible diagnoses and/or management options • Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed • Risk of complications, morbidity and/or mortality, associated with the patient’s presenting problem. Includes need for diagnostic procedures and management options

18. Medical Decision Making

19. Time Reporting: CPT Counseling Rule • Use when the time spent in ‘counseling and coordination of care’ > 50% of the E&M visit • The 3 key components of history, PE, MDM may be ignored • Only time is used to select the level of care • A summary of the ‘counseling’ discussion should be included with the note • Does not include screening time • Reported separately, with modifier (-25) Believe me, this is the best way to get paid for visits focused on developmental and behavioral problems

20. Preventive Medicine Services • E/M services performed in the absence of a significant problem/abnormality • Extent and focus depends on the patient’s age • Included counseling/anticipatory guidance/risk factor reduction

21. Preventive Medicine Services • New Patient Initial E/M of a new patient including an age and gender appropriate history, examination identification of risk factors, ordering of appropriate tests, and counseling RVU/2003 Medicare • 99381 Age< 1 year 2.75/$101.16 • 99382 Ages 1-4 years 2.96/$108.89 • Established Patient Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk factors, ordering of studies, and counseling RVU/2003 Medicare • 99391 Age< 1 year 2.08/$76.51 • 99392 Ages 1-4 years 2.33/$85.71

22. Office Visits-New Patient

23. Office Visits-Established Patient

24. Consultations • Consultation is a service provided by a physician whose opinion or advice is requested by another physician or other appropriate source • Consultant may initiate diagnostic and/or therapeutic services • Consultant must document: -Request for consultation (written or verbal) -Need for consultation -Opinion and services ordered and performed -Communication by written report back to the referring source

25. Office Consultation/ New or Est

26. Prolonged Services(99354-99359) • Code series defining prolonged services by: • Site of service • Direct or without direct patient contact • Time • Reported in addition to other physician services, including E/M services at any level • Total time for a given date, even if the time is not continuous • Time must be of 30 minutes or more

27. Prolonged Services

28. Modifiers • Services altered by specific circumstance Tells insurer “this visit is different” -21 Prolonged E/M Service -25 Significant separately identifiable E/M Service by the same physician on the same day • Used to report developmental screening with E/M code -32 Mandated Services -52 Reduced Services