Coding for Occupational Health Encounters

1. Coding for Occupational Health Encounters How to Get the Workload Credit You Deserve Angela N. Andersen, CPC Lead Coder Naval Medical Center Portsmouth March 2008

2. E&M Coding Upon completion of this presentation, the participant should be able to: Identify the three key components of E&M coding Recognize the difference between new and established patients as it relates to documentation and coding. More accurately document and select the appropriate E&M code for the services rendered.

3. Contents: What are E&M Codes? Why Code? How do Codes equate to Workload Credit? Why is Documentation important? What documentation should be included on every encounter? Determining the correct E&M code Time as the determining factor for E&M code selection Preventive Medicine E&M code requirements

4. What are E&M Codes? The Evaluation & Management (E&M) codes are a sub-set of the CPT codes. Can be used by all privileged providers Describes: Complexity of care provided to a patient for non-procedural visits. The place of service (inpatient or outpatient) The type of service (new vs. est., consult, preventive, ER, critical care, etc)

5. Why Code? Why is it important to code in the military? REIMBURSEMENT Third Party Payers/Inter-agencies Prospective Payment System (PPS) FITREP input Over coding = Fraud Under coding = Lost RVUs/Revenue Why should we care about coding?? This is the military! FITREPs: Productivity standards are a FITREP bullet. Third Party Payers/Interagencies: FY05 this command brought it $_________ thru third party payers and interagency billing (CG) Learn to work smarter, not harder when it comes to coding. Make your coding ironclad, not able to be challenged by anyone. Allow your coder to help you.Why should we care about coding?? This is the military! FITREPs: Productivity standards are a FITREP bullet. Third Party Payers/Interagencies: FY05 this command brought it $_________ thru third party payers and interagency billing (CG) Learn to work smarter, not harder when it comes to coding. Make your coding ironclad, not able to be challenged by anyone. Allow your coder to help you.

6. Coding & Workload Credit A Relative Value Unit (RVU) is assigned to most of the CPT codes, including the E&M codes. The more complex the service, the higher the RVU value assigned New Patient RVUs > Established Patient RVUs Consult RVUs > New patient RVUs Prev Med RVUs > Established patient RVUs Under the PPS, RVU average = $72.00

7. What do Coders look for? Every patient encounter should be legible and include: Date of Encounter* Reason for the visit (chief complaint) Appropriate history of present illness An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent) Review of lab, xray, other ancillary services when appropriate Assessment* Plan of care/Treatment options* Provider signature* *Taken Care of or required fields in AHLTA (CHCSII) Remember: It is the Content, not the volume, of documentation that determines your E&M code!

8. Determining the Correct E&M Code There are three key components to consider when selecting the appropriate E&M: History Exam Medical Decision Making (MDM) All three components must be documented for a new patient (new to clinic or not seen within the past three years). Indicate in CC if patient is new. Only two of the three components must be documented for established patients (seen within the past three years). E&M selection should never be based on the allotted time on the appointment schedule!

9. Why is Documentation Important? The documentation must support the E&M code you select. Your documentation must support the medical necessity of the services provided. The first step is to clearly document the reason for every visit � the chief complaint. The use of �Follow-up� is insufficient documentation as it does not indicate medical necessity. It is acceptable to document �Follow-up for _____�. Remember: The coding rule of thumb is �If it isn�t documented, it wasn�t done!�

10. Determining the Correct E&M Code To determine the correct level E&M code, consider the complexity of your patient�s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam. Remember: For a new clinic patient, initial consult, initial inpatient visit or ED encounter, you must document all three key components�history, exam and your medical decision making.

11. MDM Component Medical Decision Making (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option. It is measured by documentation of the following: Number of diagnoses and/or management options that must be considered. Amount and/or complexity of data to be reviewed. Risk of complications, morbidity and/or mortality, and co-morbidities. The four types of MDM include: Straightforward, Low Complexity, Moderate Complexity, and High Complexity. To assist in determining your level of MDM see Attachment A

12. History Component Documentation of History includes: Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past, Family and or/Social History (PFSH) The extent of history is dependent on clinical judgment and the nature of the presenting problem. The four types of History include: Problem focused, Expanded Problem focused, Detailed and Comprehensive.

13. Determine your Documented Level of History Mark the entry in the farthest right column to describe your HPI, ROS and PFSH. If one column contains 3 marks, the type of history is indicated at the bottom. If no column has 3 marks, the column marked farthest to the left identifies the type of history.

14. Exam Component The following Body Areas and Organ Systems are recognized in E&M documentation: Body Areas Organ Systems Head/Face Constitutional (vitals,etc) Neck Eyes Chest/breasts/axillae Ears/nose/mouth/throat Abdomen Cardiovascular Genitalia/groin/buttocks Respiratory Back, including spine Gastrointestinal Each extremity Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic The four types of Exam include: Problem focused, Expanded Problem focused, Detailed and Comprehensive. To assist in determining your level of PE see Attachment B

15. Final E&M Selection Determining your Level of Service: PF = Problem Focused SF = Straightforward EPF = Expanded Prob Focused L = Low Complexity D = Detailed M = Moderate Complexity C = Comprehensive H = High Complexity

16. Determining the Correct E&M Code Consider the patient who has multiple chronic problems requiring prescription drug management. This patient would be considered a moderately complex patient and with the proper documentation of the other two components (Hx and Exam) this can be coded as a level four E&M visit. For a new patient/consult level IV visit (99204, 99244): Need to document a comprehensive history and comprehensive exam. For an established patient level IV (99214): Need to document a detailed history and/or detailed exam.

17. Time as a Key Component If more than 50% of your time with a patient is spent counseling or coordinating care, time can be used in selecting the E&M level. Document counseling topics/coordination of care. Prognosis, differential diagnoses, risks/benefits of treatment, compliance, discussion with another healthcare provider Document provider�s total face-to-face time plus time spent counseling or coordinating care for patient. Example: 45 min visit/30min counseling **Do not include resident/support staff time with patient. Your documented History, Exam and MDM may only qualify for a 99214, but with the correct documentation of counseling or coordinating of care, this 45 minute visits could be coded as a 99215.Your documented History, Exam and MDM may only qualify for a 99214, but with the correct documentation of counseling or coordinating of care, this 45 minute visits could be coded as a 99215.

18. Preventive Medicine New Patient 99381-99387 Established Patient 99391-99397 Counseling 99401-99404 Individual 99411-99412 Group 99381-99397 are based on the age of the patient 99401-99412 are based on time spent counseling.

19. Preventive Medicine 99381-99397 This code series includes counseling / anticipatory guidance / risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination. Comprehensive in this code series is NOT synonymous with the comprehensive examination required in 99201-99350. 99401-99412 This code series cannot be coded on the same day as a preventive medicine examination visit. To code for these services the patient cannot have any symptoms or an established illness.

20. Capture More Workload Smoking Cessation Counseling G0375 3-10 minutes G0376 10+ minutes Digital Rectal Exam for Prostate Cancer Screening G0102 Visual Acuity Exam (Snellen Chart) 99173 Needle Sticks!! 96150 � when the OH nurse see�s a patient due to a needle stick he/she can code this encounter as 99499 E/M and 96150 CPT with the applicable ICD-9 primary for the wound and a secondary ICD-9 code of the External cause.

21. Common Coding Errors in OH V68.0x Issuance of Certificate This is a PRIMARY only ICD-9 code and should not be used in the secondary diagnosis slot. V70.x General Medical Exam This is a PRIMARY only ICD-9 code and should not be used in the secondary diagnosis slot. Routine visits that turn into an Acute visit for a finding upon exam. Providers must document all applicable information required for the preventive service. If an acute finding is discovered and managed during the same encounter � the provider should �Expand� his/her documentation pertinent to this finding and code an ADDITIONAL separate E/M code for the acute finding.

22. Common Coding Errors in OH Coding in AHLTA � You MUST verify the E/M code chosen by AHLTA in the Disposition screen. It has been a common place error that providers are being given non-count E/M code 99429 for preventive visits OR Preventive E/M 99381-99397 for acute care visits. New patient vs. Established patient While the front desk books these appointments � providers should always double check the patients �status� in AHLTA. New patients are worth higher RVU�s and you will lose out if you let the system default to an established patient E/M. Preventive Medicine and Acute Care � Same Day AHLTA will not automatically code your encounter with a Preventive E/M (99381-99397) and an Acute E/M (99201-99215). The provider must manually code the additional E/M code in the disposition screen based on his/her documentation. *Be sure to add a 25 modifier to your Acute E/M.

23. E/M RVU�S 99201 0.45 99202 0.88 99203 1.34 99204 2.30 99205 3.00 99211 0.17 99212 0.45 99213 0.92 99214 1.42 99215 2.00 99384 1.53 99385 1.53 99386 1.88 99387 2.06 99394 1.36 99395 1.36 99396 1.53 99397 1.71 99358 2.10 99359 1.00 99401 0.48 99402 0.98 99403 1.46 99404 1.95 99411 0.15 99412 0.25

24. PROCEDURAL RVU�S 94010 0.17 99000 0.05 36415 0.06 99173 0.00 96150 0.50 96151 0.48 93000 0.17 93010 0.17 G0375 0.24 G0376 0.48 G0102 0.17

25. Summary Are you going to let RVU�s slip away? By incorporating some of the information discussed today into your notes, you can honestly increase your RVU�s and �reimbursement�. Keep in mind that AHLTA does not code for you completely � you must always check your codes before finalizing your note. Templates are your best tool to maximize your coding in AHLTA.

26. Questions? Contact Information: Angela N. Andersen, CPC Office 757.953.1241 Cell 757.333.2066 Angela.Andersen@med.navy.mil