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CPT Coding and Why You Care. Ted A. Bonebrake , M.D. CPT Coding. Current Procedural Terminology System of coding medical encounters for billing purposes in the US First published by AMA in 1966 Updated annually on January 1. CPT Coding. E & M Codes (Evaluation and Management)

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cpt coding and why you care

CPT Codingand Why You Care

Ted A. Bonebrake, M.D.

cpt coding
CPT Coding
  • Current Procedural Terminology
  • System of coding medical encounters for billing purposes in the US
  • First published by AMA in 1966
  • Updated annually on January 1
cpt coding1
CPT Coding
  • E & M Codes (Evaluation and Management)
  • Procedural Codes
  • Pathology, Laboratory, Radiology
cpt coding2
CPT Coding

Why do we care?

  • Correct coding results in correct reimbursement
  • Coding errors can result in claim rejection, rebilling and delayed reimbursement
  • Providers are responsible for errors
  • Incorrect coding may result in charges and fines
reimbursement
Reimbursement
  • Most family physicians today are employees of a clinic or hospital system
  • Part or all of physician compensation is based on production.
reimbursement1
Reimbursement
  • Salaries and/or bonuses are typically based on production which is determined one of two ways:
    • Gross receipts minus overhead
    • RVU’s (Relative value units)
  • Either method is ultimately determined by the CPT codes that a provider bills for.
incorrect coding
Incorrect Coding
  • False Claims Act 1986
  • HIPAA 1996
  • The Office of Inspector General (OIG) and the Department of Justice enforce federal, state, and local laws to control healthcare fraud and abuse
  • They conduct investigations and audits pertaining to the delivery of and payment for healthcare services.
incorrect coding1
Incorrect Coding
  • In egregious cases, a doctor can be fined, excluded from Medicare and Medicaid, lose their medical license, and even do jail time.
  • More commonly, the government imposes financial penalties.
incorrect coding2
Incorrect Coding
  • The civil monetary penalty for healthcare fraud has been increased from $2000 to $10,000 for each item or service for which fraudulent payment has been received.
  • The monetary assessment has been increased from not more than twice the amount to not more than three times the amount of the overpayment.
incorrect coding3
Incorrect Coding
  • Two practices have been added to the list of fraudulent activities for which civil monetary penalties may be assessed:

1. Engaging in a pattern of presenting claims based on a code that the person knows or should know will result in greater payments than appropriate.

2. Submitting a claim or claims that the person knows or should know is for a medical item or service that is not medically necessary.

audits and investigations
Audits and Investigations

What will trigger an audit or investigation?

  • A pattern of “upcoding”
  • Whistle blowers
  • E & M codes that are consistently different than average distributions for your specialty
  • Within a group setting, inconsistent coding among partners.
audits and investigations1
Audits and Investigations

What will trigger an audit or investigation?

  • Excessive use of a code.
  • Coding level 5 services and not preventive medicine codes for annual physicals.
  • Use of symbols or shorthand
  • Lack of specificity about what you are reviewing. (Review of systems as unremarkable is insufficient)
  • Frequent coding based on “time”
slide13

New Pt Code Actual Medicare Difference

99201 5% 1.3% 3.7 points

99202 20% 15.9% 4.1 points

99203 60% 45.4% 14.6 points

99204 15% 30.5% -15.5 points

99205 0% 6.9% -6.9 points

EstPt Code Actual Medicare Difference

99211 8.3% 3.7% 4.6 points

99212 8.3% 4.3% 4 points

99213 58.3% 48.2% 10.1 points

99214 16.7% 40.2% -23.5 points

99215 8.3% 3.6% 4.7 points

procedural coding
Procedural Coding
  • There is a code for every procedure that physicians perform
  • Each code dictates the price for that service that will be charged by the physician
procedural coding1
Procedural Coding
  • Each code is a five-digit number, which identifies the procedure or service
  • Health care entities (hospitals, clinics, individual providers) attach a price to each code
  • Actual reimbursement will vary depending on what insurance companies or government payers will allow
procedural coding2
Procedural Coding

Organization of codes

  • Anesthesia 00100-01999; 99100-99140
  • Surgery 10021-69990
  • Radiology 70010-79999
  • Pathology & Lab 80048-89356
  • Medicine 90281-99199; 99500-99602
procedural coding3
Procedural Coding

Add-on codes

  • Additional procedures that are commonly done in addition to the primary procedure
  • Identified by terms like “each additional”
  • Performed by same physician
  • Cannot be reported separately
procedural coding4
Procedural Coding

Modifiers

  • Additional two-digit code that is added to the primary CPT code
  • Format: 11300-59
  • Some modifiers are attached to E & M codes; others to procedural codes
procedural coding5
Procedural Coding

Modifiers

  • Both a professional and technical component
  • More than one physician and/or location
  • Only part of a service was performed
  • An adjunctive service was performed
  • A bilateral procedure was performed
  • Service or procedure performed more than once
procedural coding6
Procedural Coding

Global Procedure Codes

  • Most procedure codes are “global”, i.e. they include ALL care related to that particular procedure
  • May or may not include initial encounter
  • For example, fracture care includes initial evaluation, treatment (splint or cast), follow up, and treatment of complications, if done by same provider
e m coding
E & M Coding
  • Evaluation and Management
  • Billing for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents:

❖ Patient type;

❖ Setting of service; and

❖ Level of E/M service performed.

e m coding1
E & M Coding
  • The “level” of the code is then determined by three components:
    • Patient History
    • Physical Exam
    • Medical Decision Making
  • For a new patient, all 3 components are used. The lowest “level” determines the code.
  • For established patients, only 2 out of 3 are needed.
e m coding patient type
E & M CodingPatient Type
  • For purposes of billing for E/M services, patients are identified as either new or established:
    • New patient -- has not received any professional services from the physician/non-physician practitioner (NPP) or another physician (of the same specialty) who belongs to the same group practice in the past three years.
    • Established patient -- has received professional services as noted above in the past three years.
e m coding patient type1
E & M CodingPatient Type
  • “Any professional services” includes:
    • Emergency department visit
    • Treatment as an inpatient (including newborns)
    • Nursing home visit
    • Outpatient visit at any location
e m coding patient type2
E & M CodingPatient Type
  • Example #1
    • Joe comes in c/o cough. He has never been seen at FPC.
    • When reviewing his chart, you see that he had a knee replacement in 2012 at Allen.
    • Dr. Johnston was the attending physician.
    • Family Practice was consulted for medical management of his hypertension.
  • Is Joe a new or established patient for E & M Coding purposes?
e m coding patient type3
E & M CodingPatient Type
  • Example #2
    • Holly comes to the clinic for follow up of hypertension, diabetes and CHF.
    • She moved away in July 2011, but just moved back to Waterloo.
    • Her FPC chart contains a complete history, and her last office visit was 12/01/10.
    • You note that her medications were refilled by phone on 7/01/11.
  • Is Holly a new or established patient for E & M coding purposes?
e m coding patient type4
E & M CodingPatient Type
  • Example #3
    • While you are on team, you admit Alfred for CHF. Dr. Kettman is his PCP.
    • The following year, Alfred changes insurance carriers, and can no longer see Dr. Kettman.
    • He remembers the excellent care you gave him in the hospital, and comes to FPC to see you for his CHF.
  • Is Alfred a new or established patient for E & M coding purposes?
e m coding setting of service
E & M CodingSetting of Service
  • E/M services are categorized into different settings depending on where the service is furnished. Examples of settings include:

❖ Office or other outpatient setting

❖ Hospital inpatient

❖ Emergency department

❖ Nursing facility

❖ Home

e m coding setting of service1
E & M CodingSetting of Service
  • In each setting, there different types of services which may be billed.
  • OFFICE
    • Office visit
    • Office consultation (new or est.)
    • Preventive medicine services
  • Nursing Facility
    • Initial nursing facility care (new or est.)
    • Subsequent nursing facility care
    • Nursing facility discharge
e m coding setting of service2
E & M CodingSetting of Service
  • Hospital
    • Initial hospital care (new or est.)
    • Subsequent hospital care
    • Observation (admit/discharge same day)
    • Hospital discharge
    • Inpatient consultation
  • Emergency Department
    • Emergency department visit (new or est.)
    • Physician direction of EMS care
e m coding setting of service3
E & M CodingSetting of Service
  • Critical Care
    • May be billed in hospital or ED setting
    • Critical care E/M (first 30-74 minutes)
    • Critical care (each additional 30 minutes)
  • Domiciliary or Rest Home Services
  • Home Services
e m coding setting of service4
E & M CodingSetting of Service
  • Prolonged Services
    • With direct patient contact
    • Without direct patient contact
  • Anticoagulant Management
  • Medical Team Conferences
  • Care Plan Oversight Serices
    • Home health agency
    • Hospice
    • Nursing facility
e m coding level of service provided
E & M CodingLevel of Service Provided
  • In general, the more complex the visit, the higher the level of code the physician or NPP may bill within the appropriate category.
  • In order to bill any code, the services furnished must meet the definition of the code.
  • It is the provider’s responsibility to ensure that the codes selected reflect the services furnished.
e m coding level of service provided1
E & M CodingLevel of Service Provided
  • There are three key components when selecting the appropriate level of E/M service provided:
    • Patient History
    • Physical Examination
    • Medical Decision Making
  • The criteria for each component varies depending on the setting and type of service.
e m coding level of service provided2
E & M CodingLevel of Service Provided
  • Visits that consist predominately of counseling and/or coordination of care are an exception to this rule.
  • For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.
e m coding level of service provided5
E & M CodingLevel of Service Provided

Patient History Definitions

  • Problem Focused: CC, brief HPI
  • Expanded PF: CC, brief HPI, pertinent ROS
  • Detailed: CC, extended HPI, extended ROS, pertinent PMH, FH and/or SH
  • Comprehensive: CC, extended HPI, complete ROS, complete PMH, FH and SH
e m coding level of service provided6
E & M CodingLevel of Service Provided

Patient History Definitions

  • HPI Elements: (Brief 1-3; Extended 4+)
    • Location
    • Duration
    • Severity
    • Modifying factors
    • Context
    • Timing
    • Quality
    • Associated symptoms
e m coding level of service provided7
E & M CodingLevel of Service Provided

Patient History Definitions

  • ROS Definitions
    • Pertinent=1
    • Extended 2-9
    • Comprehensive 10+
e m coding level of service provided8
E & M CodingLevel of Service Provided

Organ Systems:

  • Constitutional
  • Eyes
  • ENT
  • Cardiovascular
  • Respiratory
  • GI
  • GU
  • Musculoskeletal
  • Hematologic/Lymphatic
  • Neurologic
  • Endocrine
  • Psychiatric
  • Skin
  • Allergic
e m coding level of service provided9
E & M CodingLevel of Service Provided

Physical Exam Definitions

  • Problem focused: limited exam of affected area
  • Expanded PF: limited exam of affected area and related systems
  • Detailed: extended exam of affected area and related systems
  • Comprehensive: general multisystem OR complete exam of affected system
e m coding level of service provided10
E & M CodingLevel of Service Provided

Physical Exam Definitions

  • Problem-focused: 1-5 elements in 1 or more organ systems/body areas
  • Expanded problem-focused: 6 or more elements in 1 or more organ systems
  • Detailed: at least 2 elements in at least 6 organ systems or body areas OR at least 12 elements in a single organ system
  • Comprehensive: All elements of at least 9 organ systems or body areas OR all elements of one single organ system
e m coding level of service provided11
E & M CodingLevel of Service Provided

Medical Decision Making

  • Number of possible diagnoses and/or management options
  • Amount or complexity of information
  • Risk of complications, morbidity, and/or mortality
e m coding level of service provided12
E & M CodingLevel of Service Provided

Medical Decision Making

Number of possible diagnoses and/or management options

  • STRAIGHTFORWARD:

One self-limited or minor problem

  • LOW COMPLEXITY:

* One or two self-limited problem(s) or symptom(s)

* One stable chronic illness

* Acute self-limited uncomplicated illness or injury

* Risk of complications, morbidity or mortality is low

e m coding level of service provided13
E & M CodingLevel of Service Provided

Medical Decision Making

  • MODERATE COMPLEXITY:

* Three or more or self-limited problems

* One or more chronic problems with mild to moderate exacerbation, progression or side effects

* 2 OR 3 stable chronic illnesses

* Undiagnosed new illness, injury or problem with uncertain prognosis

* Acute illness with systemic symptoms

* Risk of complications, morbidity or mortality is moderate.

e m coding level of service provided14
E & M CodingLevel of Service Provided

Medical Decision Making

  • HIGH COMPLEXITY:

* One or more chronic illnesses with severe exacerbation, progression, side effects

* Four or more stable chronic illnesses

* Acute complicated injury with significant risk of morbidity or mortality

* Acute or chronic illnesses that pose a threat to life or bodily function

* Abrupt change in bodily function (e.g., seizure, CVA, acute mental status change)

* Risk of complications, morbidity/mortality is high.