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Toolbox Drawer I, as in: I can bill office OB

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Toolbox Drawer I, as in: I can bill office OB

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    1. Toolbox Drawer I, as in: “I can bill office OB/GYN.”

    2. To try this show, choose an ICD source & a CPT source Printing out Drawers B and C should work -OR- INGENIX ICD and AMA CPT manuals would work -OR- www.home.caregroup.org --> CLINICAL portal (light purple tab) --> Clinical Resources Menu List --> Diagnosis and Procedure Codes --> two interactive code finding programs, one is from the Center for Disease Control (CDC) !

    3. Recall our fundamental “equation” of medical billing Medical Billing = WHY{ICD} + WHAT{CPT} And HIPAA says submit this electronically

    4. Laboratory staff work hard to achieve accurate results and reporting. The laboratory staff use the same medical billing equation as everyone else: BILLING = WHY{ICD} + WHAT {CPT} submitted electronically. Laboratory and pathology CPT-4 codes run from 80048 --> 89356 Since the lab staff usually do not meet the patient, they often rely on the doctor to inform them “WHY” test(s) were ordered. He who runs the test bills for it. A pregnancy test run in the office gets billed by the office.

    5. Radiology staff work hard to achieve accurate diagnostic information. Radiology CPT-4 codes run from 70010 --> 79999 The radiology staff use that same medical billing equation: BILLING = WHY{ICD} + WHAT {CPT} submitted electronically. Sometimes the radiologists need the ordering doctor to tell them “WHY” a radiological procedure was ordered. He who performs the ultrasound bills for it. Sometimes, OB/GYNs bill for their own ultrasound work.

    6. Recall Medicare’s Primary Care Exemption Act for Teaching Clinics Interns < 6 months must bring the preceptor in the exam room for key visit components at every single office visit. Preceptors must be in the exam room for all office procedures, regardless of residency year. If a “problem” visit is only discussed with the preceptor, the maximum billing level is 99203/99213 (no consults, no levels 4 or 5) The preceptor must co-sign every resident clinic note with case-specific commentary and the message “I agree” The preceptor is ultimately the “professional” charging “fees” for his or her “services”, and if these federal regulations are not followed the billing could be interpreted as fraudulent.

    7. Ready to try some billing?

    8. Let’s practice office billing in this order: Procedures & Birthdays: The classics: EMB, IUD, COLPOSCOPY, VULVAR Bx, PESSARY By extension: Prenatal care (yes!) By extension: Post-op checks (yes!) Preventative Visits The classics: Non-Medicare “GYN ANNUALS” The headache: Medicare “GYN ANNUAL” The discussion only preventative counseling session E/M Problem Visits The classics: Menstrual disorders, Pain, Incontinence, Infertility The consultation: How to achieve this level (= preceptor + letter ) “Advanced” Office Billing Modifier 25: combines E/M + Procedure codes on same bill Prenatal care when it escalates from prevention to problem

    9. Office Billing for Procedures and Birthdays

    10. In Ariadne’s box is a procedure described by a specific CPT-4 code Female genital system CPT-4 procedure codes run from 56405 --> 58999 Maternity care CPT-4 procedure codes run from 59000 -->59899 CPT-4/HCPCS codes are referenced in Drawer C and further discussed in Drawer H.

    11. Endometrial Pipelle Biopsy

    12. AA: “I am here for my EMB.” Returning, 70 years old, Medicare At AA’s previous office visit, you ordered a hemoglobin and pelvic ultrasound for her complaint of bleeding after menopause. The ultrasound revealed an endometrial stripe > 5mm, so you asked AA to return to the office today for endometrial pipelle biopsy. You comply with Medicare’s Primary Care Exemption Act by bringing your preceptor into the clinic exam room for the procedure. You review with AA the risk-benefit profile of office endometrial pipelle biopsy, and she signs the consent form. You perform the EMB and send the tissue to pathology. You give AA an appointment to return to clinic in 2 weeks.

    13. ICD-9-CM Coding: WHY did you see AA today? Medical Billing = WHY{ICD} + WHAT{CPT} 627.1 = post-menopausal bleeding

    14. CPT-4 Coding: What professional service fees will you submit to Medicare for AA’s office visit today? Medical Billing = WHY{ICD} + WHAT{CPT} 58100 = endometrial pipelle biopsy

    15. CPT-4 Coding: Who else will bill Medicare for AA’s visit today? Medical Billing = WHY{ICD} + WHAT{CPT} The pathologist will likely use your “627.1” ICD code to explain WHY this biopsy analysis was necessary (CPT-4 range for surgical pathology is 88300 --> 88399). The hospital will bill various facility fees

    16. IUD insertion Medical Billing = WHY{ICD} + WHAT{CPT}

    17. BB: “I am here for my Mirena IUD.” Returning, 35 years old, Masshealth BB has 4 children and a stable monogamous relationship. She has had contraceptive counseling and desires a MIRENA IUD. BB is menstruating today and returns for MIRENA IUD insertion. She took ibuprofen 400 mg PO one hour prior to this appointment. An office urine pregnancy test confirms as negative You comply with Medicare’s Act by recruiting your preceptor into the exam room for this procedure. You counsel BB once again about the Mirena, reviewing the risk-benefit profile, routine precautions, and she signs the consent forms. You insert a MIRENA IUD without apparent complication, and document the LOT # in your note. You ask BB to return in 3 months for a “string check”

    18. ICD-9-CM Coding: WHY did you see BB? Medical Billing = WHY{ICD} + WHAT{CPT} V25.1 = IUD insertion

    19. CPT-4 Coding: What professional service fees will you bill to Masshealth for BB’s visit today? Medical Billing = WHY{ICD} + WHAT{CPT} 81025 = Urine Pregnancy test 58300 = IUD insertion J7302 = IUD Supply, MIRENA

    20. CPT-4 Coding: Who else will bill Masshealth for BB’s visit today? Medical Billing = WHY{ICD} + WHAT{CPT} The hospital will bill facility fees

    21. Cervical colposcopy w/biopsy

    22. CC: “I am here for my colposcopy.” Returning, 40 years old, Masshealth CC has a history of abnormal PAP smears and cigarette smoking. Her recent PAP was LSIL. You comply with Medicare by recruiting your preceptor to the exam room for this procedure. You review with CC the indications and risk-benefit profile of colposcopy with biopsy. She signs the consent form. Your colposcopic impression is CIN 1. You send the biopsy tissue to pathology for evaluation. You ask CC to return to clinic in 2 weeks for review of her biopsy results.

    23. ICD-9-CM coding: WHY did you see CC? Medical Billing = WHY{ICD} + WHAT{CPT} 622.1 = CIN 1 795.00 = abnormal PAP smear, not otherwise specified Note: either code works. Notice how they come from different ICD categories -- 622.1 is from genitourinary disease while 795.00 is from symptoms and abnormal test results.

    24. CPT-4 Coding: What professional service fees will you bill to Masshealth for CC’s visit today? Medical Billing = WHY{ICD} + WHAT{CPT} 57455 = colposcopy of cervix with biopsy

    25. CPT-4 Coding: Who else will bill Masshealth for CC’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} The pathologist for surgical pathology fees The hospital for facility fees

    26. Vulvar skin biopsy

    27. DD: “ I am here for my vulvar skin biopsy.” Returning, 55 years old, BCBSMA At DD’s annual exam several weeks ago, she asked you to remove some “annoying” vulvar skin tags. On reflection, you felt comfortable removing these simple skin tags in the office yourself, rather than referring to dermatology or going to the OR, so you gave DD a return appointment for this procedure. You comply with Medicare’s Act by recruiting your preceptor into the exam room for this procedure. You review with DD the risk-benefit profile of excising these vulvar skin tags in the office, and she signs the consent form. You then excise three vulvar skin tags without apparent complication, and send the tissue specimens to pathology. You ask DD to return to the clinic in 2 weeks

    28. ICD-9-CM coding: WHY did you see DD? Medical Billing = WHY {ICD} + WHAT {CPT} 698.1 = genital pruritis 701.9 = unspecified hypertrophic and atrophic condition of skin 782.8 = change in skin texture NOTE: The first two codes are from dermatology (680 --> 709.9) while the second is from the symptoms, signs, abnormal tests category (780 --> 799.9).

    29. CPT-4 coding: What professional service fees will you bill BCBS for DD’s visit today? Medical Billing = WHY {ICD} + WHAT {CPT} 11200 = skin tag removal, up to 15 lesions 56605 = biopsy of the vulva, first specimen 56606 = biopsy of the vulva, each additional specimen Choose between 11200 and 55606 depending on what you think you did

    30. CPT-4 coding: Who else will bill BCBS for DD’s visit today? Medical Billing = WHY {ICD} + WHAT {CPT} The pathologist for surgical pathology services The hospital for facility fees

    31. Pessary Fitting & Insertion Medical Billing = WHY {ICD} + WHAT {CPT}

    32. EE: “I am here for my pessary fitting.” Returning, 75 years old, Medicare EE has pelvic prolapse which you evaluated at a previous visit with POPQ staging. EE now returns requesting a pessary trial. You fit EE with a #3 Ring Pessary You give EE a 2-week follow-up appointment

    33. ICD-9-CM Coding: WHY did you see EE? Medical Billing = WHY {ICD} + WHAT {CPT} 618.2 = prolapse of vagina and uterus, incomplete

    34. CPT-4 Coding: What professional services will you bill to Medicare for EE’s visit? MEDICAL BILLING + WHY {ICD} + WHAT {CPT} 57160 = pessary fitting and insertion A4562 = supply, pessary, non-rubber

    35. CPT-4 Coding: Who else will bill Medicare for EE’s visit? Medical Billing = WHY {ICD} + WHAT {CPT} The hospital for facility fees

    36. Birthday Billing

    37. Obstetrical Billing uses CPT-4 Maternity Procedure Codes 59000 --> 59899

    38. Obstetrical Billing uses CPT-4 Maternity Procedure Codes 59000 --> 59899

    39. Obstetrical Billing uses CPT-4 Maternity Procedure Codes 59000 --> 59899

    40. Professional Service Fee Billing for Obstetricians gets packaged into one procedure submitted post-partum One Global OB “Procedure” Package = Up to 12 antepartum visits Labor and Delivery Post-partum hospital care Post-partum office check 6 weeks later Codes 59400 --> 59622 vary by specific package components: 59400 = all of the above with NSVD 59510 = all of the above with CD 59610 = all of the above with VBAC 59618 = all of the above with TOLAC - RCD

    41. Antepartum and post-partum office visits need “tracking” for two reasons These visits contribute to the final maternity procedure CPT-4 code (submitted for the obstetrician’s global professional service fees after baby’s birth) To help other hospital departments (laboratory, radiology, facility fee coders) submit their fees in current time

    42. Try some birthday billing?

    43. FF: “I am so happy to be pregnant!” New, 35 years old, Tufts Health Plan You offer a thorough new OB intake visit and order screening tests including the routine prenatal panel, cystic fibrosis, and first trimester aneuploidy risk assessment.

    44. ICD-9-CM Coding: WHY did you see FF today? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} V22.0 = first pregnancy, routine preventative care V22.1 = not first pregnancy, routine preventative care V23.81 = first pregnancy and > 35 years old at EDC V23.82 = not first pregnancy and > 35 years old at EDC

    45. CPT-4 Coding: How should you “track” FF’s visit? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} We said already that CPT-4 billing for routine obstetrical professional services does not happen until the baby is delivered. But in the meantime, you’ll need to “keep track” of this antepartum visit -- for the sake of your own eventual professional service fees, and for the sake of hospital facility, laboratory, and radiology billing. To achieve routine obstetrical visit tracking, the hospital asks the obstetrician to check off one of the familiar E/M problem menus 99201 -->5 and 99211-->5 by room time. WARNING: DO NOT GET CONFUSED HERE: EVEN THOUGH YOU ARE USING A CPT PROBLEM VISIT MENU, YOUR CODING HERE IS ONLY USED FOR VISIT TRACKING AND FACILITY FEES.

    46. GG: “Feeling good at 28 weeks” Returning, 25 years old, BCBS GG has a reassuring OB check and completes her GDM screening test.

    47. ICD-9-CM Coding: WHY did you see GG? Medical Billing = WHY{ICD} + WHAT{CPT} V22.0 = first pregnancy, routine preventative care V22.1 = not first, routine care

    48. CPT-4 Coding: How will you TRACK GG’s antepartum visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} Your office ran a urine dipstick = 81000. Using the hospital’s “obstetrical / for facility fees only” tracking menus, you’ll check off 15 minutes of return time with the 99213 box

    49. HH: “I feel great 6 weeks post-partum!” Returning, 30 years old, Masshealth HH had normal prenatal care and vaginal delivery at BIDMC. Her post-partum examination is normal. You conclude this post-partum check with a Progestin Only Pill prescription.

    50. ICD-9-CM coding: WHY did you see HH? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} V24.2 = routine post-partum visit

    51. ICD-9-CM coding: How will you track HH’s post-partum visit? The CPT-4 global maternity procedure code 59400 was sent to Masshealth after HH’s delivery, so you the obstetrician await your $1,800 State payment. Just like the 12 antepartum visits, this post-partum visit is included within the $1,800 and needs tracking : within the “OB TRACKING / FACILITY FEES ONLY” menu check of return patient / 25 minutes = 99214.

    52. Post-operative checks are also “packaged”

    53. Office post-op checks Third party payors ASSUME that after surgery the patient will visit the office for a “routine” post-operative check, so this is included within the “global surgical package”.

    54. II: “I feel good the week after my hysteroscopy.” Returning, 45 years old, BCBS II appears well. You discuss her reassuring benign endometrial polyp result and ask her to continue a menstrual calendar.

    55. ICD-9-CM Coding: WHY did you see II? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} 621.0 = endometrial polyp V67.00 = routine post-operative check

    56. CPT-4 Coding: WHAT professional service fees will you bill to BCBS for II’s post-operative check? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} 99024 = post-operative check BCBS will most likely “package” this office post-operative visit into its global surgical fee schedule for hysteroscopy.

    57. Office Preventative Visits

    58. “GYN Annual Exams” (for patients NOT using Medicare) can be CPT-4 coded by new/return x age menus:

    59. JJ: “Help me avoid pregnancy and disease.” New patient, 25 years old, Masshealth HPI: this is an annual GYN preventative visit, so there’s no “present illness” per se, but rather the focus is on prevention. Of note: JJ had an LSIL PAP 2 years ago with normal colposcopy, followed by a normal PAP. ROS: thorough PE: vitals + breast + pelvic + whatever else you advocate OFFICE PROCEDURE: HPV vaccination ( NOTE: CPT categorizes vaccines under “medicine” not “procedure”.) TESTS RUN IN OFFICE: none TESTS ORDERED: PAP, GC and Chlamydia A/P: No disease detected. Immunize against HPV and expand disease screening with tests above. Offer Nuvaring prescription and healthy lifestyle recommendations.

    60. ICD-9-CM Coding: Why did you see JJ? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} V72.31 = Preventative Gynecological Exam V72.32 = Needs a follow-up PAP for her history of a past abnormal PAP followed by a normal PAP V25.09 = Family Planning Counseling V 04.89 = Needs “other viral” = HPV vaccine

    61. CPT-4 Coding: What professional service fees will you charge Masshealth for JJ’s visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} EE was vaccinated to HPV in your office. Again we have the works of vaccine supply and injection: Gardasil HPV vaccine supply code = 90649 CPT-4 vaccine injection code = 90471 EE is a new patient using Masshealth to pay for a preventative office visit. Using CPT-4 Preventative E/M Menu 99384 -> 99387, Age 25 years = 99385

    62. CPT-4 Coding: Who else will be billing Masshealth for JJ’s visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} The cytology lab for the PAP The micro lab for the GC/Chl The hospital for facility fees And they all might use your V72.31 ICD coding to explain WHY they did their work

    63. KK: “Help me avoid disease. ” Returning, 50 years old, NHP insurance HPI: preventative focus; KK had breast cancer 10 years ago and just ran the Boston Marathon in 3:52. ROS: Thorough, occasional hot flushes PE: Vitals + breast + pelvic + whatever else you advocate OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: CBC, TSH, Lipid Panel, Mammogram, Bone Mineral Density, Colonoscopy A/P: No disease detected. Expand disease screening with above tests. Marathon achievements respected.

    64. ICD-9-CM Coding: WHY did you see KK? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} V72.31 = Preventative Gynecological Exam V 10.3 = Personal history of breast cancer V76.11 = High risk mammogram 627.2 = Climacteric symptoms Note: Just V72.31 would suffice

    65. CPT-4 Coding: What professional service fees will you charge Neighborhood Health Plan for KK’s visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} KK is a returning patient using Neighborhood Health Plan, which is a branch of Medicaid / Masshealth, in order to pay for this preventative gynecologic visit. Using E/M Preventative Return Patient Menu 99394 --> 99397: Age 50 years = 99396

    66. CPT-4 Coding: Who else will bill NHP for KK’s visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} The clinical laboratory for blood tests The hospital for facility fees Eventually the endocrinologists, radiologists, and gastroenterologists for their screening procedures.

    68. LL: “Please help me avoid disease.” New patient, 65 years old, MEDICARE HPI: Preventative focus. ROS: Thorough PE: vital signs, breast, pelvic, plus whatever else you advocate OFFICE PROCEDURE: influenza vaccination (technically, CPT-4 categorizes vaccines under “medicine”, not “procedure”) TESTS RUN IN OFFICE: none TESTS ORDERED: PAP smear, hemoglobin, TSH, mammogram, bone mineral density A/P: No disease detected. Expand disease screening with above tests. Disease prevention encouraged through vaccination and lifestyle recommendations.

    69. It’s the dreaded MEDICARE annual! Drawers C and H review Medicare billing for “GYN Annuals” For “GYN Annuals”, most 3rd party payers, including the state Medicaid programs, want menus 99384 -->7 and 99394 --> 7 which are simply arranged by new/return x age But when billing the federal government for office GYN prevention work, instead of the usual HCPCS Tier 1 CPT-4 Preventative E/M menus, you must submit specific HCPCS Tier 2 National menus justified by very specific ICD “V” codes (that is, if you want to get paid)

    70. How will you explain to Medicare WHY you offered LL preventative care? MEDICAL BILLING = WHY{ICD} + WHAT{CPT/HCPCS} V 04.8 = needing influenza vaccination V 76.2 for routine cervical PAP V 76.12 for screening mammogram average risk

    71. How will you charge professional service fees to Medicare for LL’s preventative visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT/HCPCS} 90658 = HCPCS Tier 1 = CPT-4 “Medicine” code, Influenza vaccine supply 90471 = HCPCS Tier 1 = CPT-4 “Medicine” code, vaccine injection G 0101 = HCPCS Tier 2 National code, breast & pelvic exam Q 0091 = HCPCS Tier 2 code for PAP collection

    72. MM: “ I need my annual GYN check” Returning, 70 years old, Medicare HPI: Preventative focus. TAH-BSO for Stage IA grade 1 endometrial cancer 5 years ago. ROS: Thorough PE: Vital signs, breast, pelvic, + whatever else you advocate OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: PAP smear, mammogram A/P: No disease detected. Expand disease screening with tests above. Encourage disease prevention through lifestyle modifications.

    73. How will you explain to Medicare why you saw MM? MEDICAL BILLING = WHY{ICD} + WHAT{CPT} V76.11 = screening mammogram, high risk patient V67.01 = vaginal PAP, past malignant hysterectomy

    74. CPT-4/HCPCS Coding: How will you bill professional service fees to Medicare for MM’s preventative GYN office visit? MEDICAL BILLING = WHY{ICD} + WHAT{CPT/HCPCS} G 0101 = pelvic and breast exam Q 0091 = PAP collection

    75. Office E/M Problem Visits

    76. E/M Office Problem Menus by weights or time

    77. E/M Weights H = History & PE = Physical Exam Problem focused Expanded Problem Focused Detailed Complete Decision Complexity Straightforward Low Moderate High

    78. Recall the E/M time rule: If > 50% of the total visit time was spent with the attending in the room for patient counseling, only in that case the total visit time can be used as the E/M office problem coding parameter. If time is used to code the visit, then the note MUST document: “ Total time with the patient __ minutes, of which > 50% was spent counseling the patient about these issues (with the clinic preceptor present).”

    79. Medicare’s Primary Care Exemption Act: Residents CANNOT bill by their time. Residents CANNOT bill higher than E/M Problem Level 3 (i.e. 99203/99213) unless they invite their preceptor into the exam room for the KEY VISIT COMPONENTS Residents CANNOT bill using the consultation menu (not shown in previous slide) unless they invite their preceptor into the exam room for the KEY VISIT COMPONENTS

    80. NN: “My period is too heavy.” New, 30 years old, BCBS insurance HPI: DETAILED PE: DETAILED OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: Hb, Pelvic US A/P: Fibroid menorrhagia, try NSAIDs + oral contraceptives, return after pelvic US. Decision complexity here is Moderate.

    81. ICD-9-CM Coding: Why did you see NN? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 626.2 = Menorrhagia 218.9 = Working Dx Fibroid Uterus

    82. CPT-4 Coding: What professional service fees will you charge BCBS for NN’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} NN is new to the practice and visited your office for evaluation and management of an active medical problem. Use E/M menu 99201 -->5. By “weights”: D + D + M = 99203. By “time”: the visit lasted 30 minutes, but less than half of that interval was spent in counseling NN, so you cannot code this visit by time (even attending physicians cannot).

    83. CPT-4 Coding: Who else will bill BCBS for NN’s visit? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} The hematology laboratory bills the Hb The radiologist bills the pelvic US The hospital bills facility fees Lab tech, radiologist, and hospital coders might use your ICD codes from clinic to complete their billing submissions

    84. OO: “My period is too painful.” Returning, 40 years old, Masshealth HPI: Detailed PE: Detailed OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: Pelvic Ultrasound A/P: Suspect Adenomyosis - Endometriosis. NSAIDs + Oral Contraceptives prescribed. Decision complexity here is Moderate.

    85. ICD-9-CM Coding: Why did you see OO? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 625.3 = Dysmenorrhea 617.0 = Working Dx Adenomyosis

    86. CPT-4 Coding: What professional service fees will you charge Masshealth for OO’s visit? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} OO is returning to the practice and visited your office for evaluation and management of an active medical problem. Use E/M menu 99211 --> 5. By “weights”: D + D + M = 99214. If your preceptor was with you for the KEY VISIT COMPONENTS you can keep the “4” level, but if not then Medicare’s Act downgrades the coding to 99213. By “time”: the visit lasted 30 minutes, but less than half of that time was spent in counseling OO, so nobody can code this visit by time.

    87. CPT-4 Coding: Who else will be charging Masshealth for OO’s visit? MEDICAL BILLING = WHY {ICD} + WHAT {CPT} The radiologist for the ultrasound The hospital for facility fees Radiologist and hospital coders might use your ICD coding from clinic in their billing

    88. PP: “ Trying 6 months for pregnancy, no success.” Returning, 42 years old, Tufts HP HPI: Detailed PE: Detailed OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: Day 3 FSH + Estradiol, PAP, GC, Chlamydia, CF, T&S, Heps B+C, HIV, CMV, pelvic US, mammogram A/P: infertility with age-related decreased ovarian reserve; needs referral asap to IVF clinic. Decision complexity here is Moderate.

    89. ICD-9-CM Coding: Why did you see PP ? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 628.0 = infertility associated with anovulation

    90. CPT-4 Coding: What professional service fees will you bill to Tufts Health Plan for PP’s visit ? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} PP is a returning patient with a problem. Use E/M Problem menu 99211 --> 99215. By weights: D + D + M = 99214, but Medicare’s Act downgrades this to 99213 because you only discussed this case with your preceptor (preceptor was not in the room for the key visit components)

    91. CPT-4 Coding: Who else will bill Tufts for PP’s visit ? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} Cytology bills the PAP Hematology lab bills all those tests Radiology will bill the pelvic ultrasound & mammogram The hospital bills facility fees And everyone might need your clinic ICD coding for their own billing

    92. QQ: “I leak pee when I run after the bus.” New, 55 years old, NHP HPI: Detailed PE: Detailed, including POPQ staging exam OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: Urine analysis and culture A/P: Obese patient with pelvic prolapse and resulting stress urinary incontinence. You ask her to complete a 2-day bladder diary and then return in 2 weeks for further counseling. Decision complexity here is Moderate.

    93. ICD-9-CM Coding: Why did you see QQ? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 625.6 = Stress Urinary Incontinence

    94. CPT-4 Coding: What professional service fees will you bill to NHP? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} New patient, E/M Problem visit. Use menu 99201 --> 99205. By weights: D + D + M = 99203. Total Visit time 45 minutes, but less than half of this was spent counseling QQ so nobody can bill this visit by time.

    95. CPT-4 Coding: Who else will bill NHP? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The laboratory will bill the UA/C The hospital will bill facility fees Lab and hospital might use your ICD coding

    96. RR: “ Itchy white vaginal discharge.” Returning, 20 years old, NHP HPI: Expanded Problem Focused PE: Expanded Problem focused OFFICE PROCEDURE: none TESTS RUN IN OFFICE: Wet Prep TESTS ORDERED: none A/P: Obvious vulvovaginal yeast infection. Diflucan prescription given. Complexity here is Low.

    97. ICD-9-CM Coding: Why did you see RR? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 112.1 = vulvovaginal candidiasis 698.1 = genital pruritis

    98. CPT-4 Coding: What professional fees will you bill to Neighborhood Health Plan for RR’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} Your office ran a wet prep test: 87210 RR is a returning patient whom you evaluated for a problem. Use E/M Problem Menu 99211 --> 5. By weights: E + E + L = 99213. RR’s visit took 25 minutes, of which less than half was spent in counseling her, so nobody can bill this visit by total time.

    99. SS: “I am here for my IUD check.” Returning, 40 years old, BCBS HPI: Problem Focused - feels fine PE: Problem focused, strings in normal place OFFICE PROCEDURE: none TESTS RUN IN OFFICE: none TESTS ORDERED: none A/P: IUD appears in normal position 3 months after insertion. Complexity here is Straightforward.

    100. ICD-9-CM Coding: Why did you see SS? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} V25.42 = IUD follow-up

    101. CPT-4 Coding: What professional service fees will you bill to BCBS for SS’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} SS returned to the office for a specific problem (her IUD management), so use E/M return problem menus 99211 --> 99215. By weights: P + P + S = 99212.

    102. CPT-4 Coding: Who else will bill BCBS for SS’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The hospital will bill facility fees

    103. Office E/M Consultation Visits

    104. CPT-4 E/M Office Consultation Menu

    105. Office “Referral” versus “Consultation” “Referral” means: MD asks another MD to take over the management of a patient’s problem. “Consultation” means: MD asks another MD for help co-managing a patient’s problem. For consultations, it does not matter if the patient is new or returning For consultations, a letter must be written back to the physician who requested the consultation. “Referrals” are billed using E/M Problem menus (99201 -->5 and 99211 -->5) , whereas “consultations” are billed using E/M consultation menus (99241-->5).

    106. Medicare’s Primary Care Exemption Act Medicare, the third party payer of most resident salaries across the USA, says that in Resident Teaching Clinics, unless the preceptor is present for the KEY COMPONENTS of a patient’s visit, consultation fee schedules may not be used. However, if the attending is present for the KEY COMPONENTS of a consultation visit, then the E/M Office Consultation CPT-4 menus can be used and they work analogously to the E/M Office Problem menus -- i.e. by weights or counseling time

    107. Dr. Smith consults you on patient TT: “ I only have three periods per year.” 28 years old, Tufts Health Insurance Your preceptor is present in the exam room to review the key components of the history, physical examination, and counseling discussion. A letter is written back to Dr. Smith in consultation, co-signed by both resident and attending. HPI: Complete PE: Complete OFFICE PROCEDURE: none TESTS RUN IN OFFICE: urine pregnancy TESTS ORDERED: free testosterone, lipid panel, fasting glucose, TSH, FSH, pelvic ultrasound A/P: PCOS - metabolic syndrome is your working diagnosis. You recommend nutritional counseling for weight optimization, as well as oral contraceptives for cycle control. The decision complexity here is Moderate.

    108. ICD-9-CM Coding: Why did you see TT? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 256.4 = PCOS 278.00 = Obesity 626.1 = Oligomenorrhea

    109. CPT-4 Coding: What professional service fees will you charge Tufts Health Plan for TT’s visit? 81025= urine pregnancy test The attending preceptor was present in the examination room for the KEY VISIT COMPONENTS, and a letter was sent back to Dr. Smith, so use CPT-4 Consultation menu 99241 --> 5. By “weights”: C + C + M = 99244 If resident and preceptor only discuss a case, then Medicare’s Primary Care Exemption Act prohibits Consultation levels. Instead, the Problem E/M menu for a new patient would be used: 99201 -->5 with the weights in this case C + C + M = 99204. However, again, Medicare’s Act downgrades resident-preceptor discussion only office visits to a maximum level of 99203. Total visit time was 45 minutes, of which you spent 15 counseling CC about PCOS. Since less than half of this visit was spent in counseling, time CANNOT be used as the billing parameter, even for attendings.

    110. CPT-4 Coding: Who else will bill Tufts for TT’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The lab The radiologist The hospital facility fee coder

    111. Dr. Finch consults you on patient UU CC: “ My pelvis has been hurting for 4 years.” 30 years old, Tricare Your preceptor is present in the exam room to review the key components of the history, physical examination, and counseling discussion. A letter is written back to Dr. Finch in consultation, co-signed by both resident and attending. HPI: Complete PE: Complete OFFICE PROCEDURE: none TESTS RUN IN OFFICE: urine pregnancy TESTS ORDERED: PAP, GC, Chlamydia, CBC, TSH, pelvic US A/P: Chronic Pelvic Pain with associated major depressive disorder is your working diagnosis. A multidisciplinary approach via Dr. Finch + GYN + GI + Psychiatry + Pain Clinic is what you think will be necessary. You give UU monthly appointments x 4 months and ask her to complete a pain diary for this upcoming month. The decision complexity here is Moderate.

    112. ICD-9-CM Coding: Why did you see UU? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 625.0 = Dyspareunia 625.3 = Dysmenorrhea 625.9 = Pelvic Pain, Not otherwise specified 305.1 = Tobacco Abuse 305.5 = Opioid Abuse 311 = Major Depressive Disorder, NOS

    113. CPT-4 Coding: What professional service fees will you charge Tricare for UU’s visit? 81025= urine pregnancy test The attending preceptor was present in the examination room for the KEY VISIT COMPONENTS, and a letter was sent back to Dr. Finch, so use CPT-4 Consultation menu 99241 --> 5. By “weights”: C + C + M = 99244 By time: Total visit time was 60 minutes, of which you spent 35 counseling UU about her pain. Over 50% of this visit was spent counseling UU about her pain, and so you can use time as your coding parameter ; looking at the tables, 60 minutes of consultation still equals 99244. If resident and preceptor only discuss a case, Medicare’s Primary Care Exemption Act prohibits Consultation levels. Instead, the Problem E/M menu for a new patient would be used: 99201 -->5 with the weights in this case C + C + M = 99204. However, again, Medicare’s Act downgrades resident-preceptor discussion only office visits to 99203 maximum.

    114. CPT-4 Coding: Who else will bill Tricare for UU’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} Lab Multi-disciplinary physician teams Hospital facility fee coder

    115. Modifer # 25, Other Modifiers, & “Advanced” Billing

    116. Modifer # 25 & “Advanced” Billing #25 CPT-4 Modifiers are 2-digit numbers appended to CPT-4 codes which third party payers require in particular situations.

    117. Modifer # 25 & “Advanced” Billing #25 Modifier # 25 is very important for OB/GYN clinics, because it allows the doctor to charge E/M work and Procedure work for the same visit.

    118. Modifer # 25 & “Advanced” Billing #25 Pretend you combine E/M problem work for a new patient (menu 99201 --> 99205) with an endometrial pipelle biopsy (58100). You must check off Modifier # 25 or else your billing will get rejected.

    119. Modifer # 25 & “Advanced” Billing #25 Pretend you combine E/M office problem work for a returning patient (menu 99211 --> 99215) with a PARAGUARD IUD insertion (58300 + J7300). You must check off Modifier # 25 or else your billing will get rejected.

    120. Modifer # 25 & “Advanced” Billing #25 Pretend you combine E/M consultation work (menu 99241 --> 99245) with a pessary fitting ( 57160 + A4562). You must check off modifier # 25 or else your billing will get rejected.

    121. Modifer # 25 & “Advanced” Billing #25 Pretend you perform a preventative GYN exam for a new 60 year old patient (99386) but at that same visit you perform an endometrial pipelle biopsy (58100). You must check off Modifier # 25 or else your billing will get rejected.

    122. Modifer # 25 & “Advanced” Billing #25 Pretend you perform an E/M office problem visit for a returning patient (menu 99211 --> 5) and diagnose missed spontaneous abortion (ICD-9-CM = 632). You book the patient for the OR tomorrow for a minor procedure D&E (59820). You must check off Modifier # 25 on your office billing ticket today or else the work of today’s diagnosis and counseling will get rejected by the third party payer and instead “lumped” into tomorrow’s minor surgical procedure fee.

    123. Modifer # 25 & “Advanced” Billing #57 Pretend you are in the ED and evaluating a tachycardic, hypotensive patient with a positive pregnancy test ( E/M menu 99201 --> 99205) and you diagnose a bleeding ectopic pregnancy (ICD-9-CM = 633.90). You are taking the patient to the OR for emergency laparotomy. In this case, Modifier # 57 would indicate that this evaluation and management led to your decision to take your patient to the operating room.

    124. Modifer # 25 & “Advanced” Billing #82 Pretend all OB/GYN residents have gone club hopping in New York City, so attendings need to assist each other at operations. The attending who assists another attending when no resident is available bills his or her operative assistance work using modifier # 82.

    125. Ready for some tougher coding cases?

    126. AB: “I want to quit smoking.” Returning, 44 years old, Tufts Health Plan AB wants to quit smoking, but she’s having trouble, and she seeks your advice. You spend 15 minutes of clinic time talking with AB about smoking cessation strategies. There is no formal physical exam, although you do note general appearance and vitals. You are a resident, and no preceptor has been in the room for this preventative discussion.

    127. ICD-9-CM Coding: WHY did you see AB? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 305.1 = tobacco abuse

    128. CPT-4 Coding: What professional service fees will you charge to Tufts Health Plan for AB’s visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The preceptor was not in the room, and Medicare’s Act prohibits residents from CPT-4 coding by their own time. So you cannot use the Preventative Discussion Only Menu 99401 --> 4 because this menu codes by time. But now you realize that by simply observing AB’s general appearance, you have one point on the physical exam scale. This gives you a problem focused exam. You took the smoking history, and you did make some recommendations about cessation too. P + P + S = 99212. And as usual the hospital will generate its facility fees

    129. VV: “ I seem to be having a period this month.” New, 70 years old, Medicare HPI: Detailed. She is diabetic. PE: Detailed. She is hypertensive and obese. OFFICE PROCEDURE: Endometrial Pipelle Biopsy TESTS RUN IN OFFICE: None TESTS ORDERED: PAP smear, Pathology for the biopsy, Pelvic Ultrasound (may as well...) A/P: The decision complexity here is Moderate.

    130. ICD-9-CM Coding: WHY did you see VV? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 627.1 = bleeding per vagina after menopause 250.02 = NIDDM, no systemic complications yet, but not in good control 278.0 = Obesity 401.9 = hypertension, NOS (not otherwise specified)

    131. CPT-4 Coding: What will you bill Medicare in professional service fees for VV’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} For your new patient E/M problem work (menu 99201 -->5), by weights your coding would be D + D + M = 99203. In this case, the total visit time was 45 minutes of which only 15 were spent in counseling, so billing by time does not apply for anyone. The CPT-4 procedure code for endometrial pipelle biopsy is 58100. Notice that for the same visit, you are charging fees for both E/M work (99203) and Procedure Work (58100). You must emphasize to the third party payer that this dual billing is not in error by checking off Modifier # 25, otherwise your billing will get rejected.

    132. CPT-4 Coding: Who else will bill Medicare for VV’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The radiologist who eventually performs VV’s pelvic ultrasound The cytologist who interprets VV’s PAP smear The pathologist who interprets VV’s endometrial biopsy The hospital for facility fees & Everyone on this list might need your ICD-9-CM office coding for their billing

    133. WW: “9 weeks pregnant but spotting today.” Returning, 41 years old, Aetna HPI: Expanded Problem Focused PE: Expanded Problem Focused. OFFICE PROCEDURE: You perform a transvaginal ultrasound and find an intrauterine pregnancy with a 1 cm embryo but NO cardiac activity. TESTS RUN IN OFFICE: None TESTS ORDERED: You send WW downstairs to radiology for a “formal” pelvic ultrasound which confirms your findings. The diagnosis is a missed spontaneous abortion at 9 weeks. A/P: Medical complexity in this case is Moderate. You discuss with WW her management options - expectant, misoprostol, D&E - and she prefers D&E. You now proceed to listen to her heart and lungs, check her neck and extremities to complete a pre-operative H&P and you add WW’s D&E to the OR schedule for tomorrow.

    134. ICD-9-CM Coding: WHY did you see WW? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 632 = missed spontaneous abortion V26.4 = fertility counseling

    135. CPT-4 Coding: What professional service fees will you bill to BCBS for WW’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} WW is a returning patient with a problem -- she has a miscarriage, so this is no longer a “routine OB visit” even though she has trophoblast cells in her body making hCG. Eventually, you completed a full pre-operative H&P, so the final E/M coding by weight would probably be D + D + M = 99214. Now, Medicare’s Act downgrades this to 99213 unless the attending was present for the KEY visit components. You performed a transvaginal ultrasound with CPT-4 radiology code of 76817, but then you asked radiology to confirm your impression. This billing should go to radiology. You booked your patient for a minor D&E procedure (59820) for tomorrow. To get paid for today’s office work, you must check off Modifier # 25 to emphasize that today’s work should not be “packaged” into the bill for tomorrow’s minor procedure.

    136. CPT-4 Coding: Who else will bill BCBS for WW’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} Radiology for their pelvic ultrasound (and not you for the one you did - yours wound up being “extra”) The hospital for facility fees

    137. Returning, 40 years old, Masshealth XX: “ 36 weeks pregnant and I feel fine.” HPI: Normal interval PE: Normal checkpoints, BREECH by Leopold’s OFFICE PROCEDURE: Limited TA US confirms breech TESTS RUN IN OFFICE: Urine Dipstick TESTS ORDERED: GBS A/P: Breech, AMA @ 36 weeks. Breech counseling x 15 minutes.

    138. ICD-9-CM Coding: WHY did you see XX? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} V23.82 = not 1st pregnancy, > 35 at EDC V22.1 = routine obstetrical visit 652.23 = breech, no version tried yet

    139. CPT-4 Coding: What will you bill to Masshealth for XX’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 81000 = Urine Dipstick 76815 = TA OB US, Limited: residents can try coding this to generate facility fees (but try not to compete with radiology) We’ve already discussed how routine prenatal visits are “packaged” into one maternity procedure code billed after delivery, so coding for these visits is only for tracking and facility fee purposes. Now, in this case, does the “breech” diagnosis tempt you to bill for an E/M Office Problem visit using the return patient menu 99211 --> 99215? Yes, you could try this, but Masshealth will most likely reject your proposal. Masshealth expects that you, as the primary obstetrician, will see XX for up to 12 “routine” preventative prenatal office visits. Unless XX has exceeded 12 visits, you will have a difficult time convincing Masshealth that you ought to be paid “extra” for this visit.

    140. CPT-4 Coding: Given this “global package” system of obstetrical reimbursement, how can MFMs bill office consultations? As consultants, MFMs can bill for obstetrical office consultations using the coding menu 99241 --> 99245. Knowing what you know about CPT-4 E/M Consultation Codes, it won’t surprise you that: MFMs write formal letters back to the primary consulting obstetricians When their counseling time is > 50% of the total office visit time, MFMs often choose the TIME scales for the 99241 --> 5 consultation menu and document in their note: “Total visit time ___ minutes, of which over half the time was spent in counseling patient __ about her diagnosis of __.” MFMs can bill for their office ultrasounds.

    141. CPT-4 Coding: Who else will bill Masshealth for XX’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} The laboratory for the GBS screen The hospital for facility fees -- if a resident appropriately checks off the limited OB ultrasound code, that might generate additional facility fees

    142. YY: “ My chlamydia screen was positive at my New OB check.” Returning, 20 years old, Masshealth HPI: Normal interval for the pregnancy; you obtain a more expanded sexual history PE: Normal OB checkpoints OFFICE PROCEDURE: none TESTS RUN IN OFFICE: Urine Dipstick TESTS ORDERED: none A/P: 14 weeks pregnant, chlamydial cervicitis, counseling and Rx Azithromax provided.

    143. ICD-9-CM Coding: WHY did you see YY? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 099.5 = chlamydia, venereal 616.0 = cervicitis V22.0 = routine prenatal care

    144. CPT-4 Coding: What professional service fees will you bill to Masshealth for YY’s visit today? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} 81000 = Urine dipstick analysis run by the office Here we go again. Does the diagnosis of chlamydial cervicitis merit its own E/M Office Return Problem Fee Code (e.g. 99213) -- or should this visit for chlamydial cervicitis only get “tracked” and eventually “packaged” into that one final maternity procedure fee submitted post-partum? When you are in practice, you can try coding these situations in different ways, and see how the third party payers respond. Most of them will adopt the “package” approach of payment to the primary obstetrician for 12 expected antepartum visits in which “the usual” obstetrical issues are addressed.

    145. ICD-9-CM Coding: Who else will bill for XX’s antepartum visit? MEDICAL BILLING = WHY {ICD} + WHAT{CPT} As usual, you tracked this antepartum visit so the hospital can bill facility fees

    146. ZZ: “ 30 weeks pregnant and moving to Arizona!” Returning, 30 years old, BCBS You complete ZZ’s 6th routine antepartum visit and hand her a copy of her antepartum record for her new doctors in Arizona. You alert your billing office that ZZ’s final CPT-4 maternity procedure code, from the standpoint of this practice, will be: 59425 = Antepartum Care only, 4-6 visits

    147. Well, it’s been real. Good Luck and May your coding reflect the work of a great doctor!

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