Coding 2010 ASTHMA

1. Coding 2010ASTHMA Richard H. Tuck, MD, FAAP

2. Using and Reporting ICD-9-CM Codes 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-CM code that is identified as the main reason for the service first. Next list any current coexisting conditions. Chronic disease treated on an ongoing basis may be coded

3. Asthma ICD Coding • Not consistent with current asthma diagnostic criteria in ICD-9 • Will be revised to meet diagnostic criteria in ICD-10 • Code symptoms until confident of asthma diagnosis

4. Asthma ICD CodingSymptoms • 465.9 URI • 466.0 Bronchitis • 466.19 Bronchiolitis • 486 Pneumonia • 519.11 Acute bronchospasm • 786.05 Shortness of breath • 786.06 Tachypnea • 786.07 Wheezing • 786.2 Cough

5. Asthma ICD CodingAsthma Diagnosis • Note fifth digit classification • 0 unspecified • 1 with status asthmaticus • 2 with (acute) exacerbation • 493.x Asthma

6. Asthma ICD CodingAsthma Diagnosis • 493.0 Extrinsic asthma • 493.00 childhood w/o status • 493.01 childhood with exacerbation • 493.1 Intrinsic asthma • 493.2 Chronic obstructive asthma • 493.81 Exercise induced asthma • 493.82 Cough variant asthma • 493.9 Asthma unspecified

7. V - Codes • V 65.11 Conference with Parent • V 65.5 Feared Illness / None Found • V 67.9 Follow up Exam • V 67.59 Follow up after Rx

8. Time • An explicit factor to assist in selecting the most appropriate level of E/M services • When counseling and/or coordination of care are more than 50% of the face to face encounter, then time is the key controlling factor. • Utilize prolonged services codes (time based) *Documentation in the medical record is a must

9. Office Visits – New Patient

10. Office Visits – Established Patient

12. Asthma 99213 → 99214 • CSHCN • New Diagnosis • Repeat visit – patient worse • Comorbidities • Lab or Xray ordered • Consultation indicated • Prescription written • Office procedures required (aerosol, pulse ox) • Chronic problem – exacerbation, changes in Rx • Time based problem/ “consultation”

13. Preventive Medicine Services • E/M services performed in the absence of a significant problem/abnormality • Extent and focus depends on the patient’s age • Include counseling/anticipatory guidance/risk factor reduction • Do not include office procedures, ancillary services, and immunizations

14. 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/ 2009 Medicare 99381 Age < 1 year 2.51/ $ 90.53 99382 Ages 1 – 4 years 2.73/ $ 98.46 99383 Ages 5 – 11 years 2.71 /$ 97.74 99384 Ages 12 – 17 years 2.95/ $106.40 99385 Ages 18 – 39 years 2.95/ $106.40

15. Preventive Medicine Services Established Patient Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk factors, ordering of studies, and counseling RVU/ 2009 Medicare 99391 Age < 1 2.09/ $75.38 99392 Ages 1 – 4 years 2.33/ $84.04 99393 Ages 5 – 11 years 2.32 /$83.67 99394 Ages 12 – 17 years 2.55/ $91.97 99395 Ages 18 – 39 years 2.56/ $92.33

16. Preventive Medicine vs E/M Office Visit ? How do you code for asthma management at the time of a preventive medicine visit?

17. 25 Modifier • If a significant problem/abnormality is found at a preventive medicine visit: • Code the appropriate E/M visit in addition to 99381 – 99395 • Add modifier –25 to the E/M code • If not significant code only 99381 – 99395 • Option: Have patient return for a separate E/M visit for asthma management

18. Office procedures • Immunizations • Minor procedures • Lab and x-ray services • Medical services • Screening procedures • Special services

19. Vaccine Coding Specifics • Each vaccine has a specific CPT code • AMA identifies vaccines pending FDA approval ~ code assigned • Each vaccine has an appropriate ICD-9 diagnosis code • Each vaccine should be linked to an individual IA (immunization administration) code

20. Immunizations • Bill and Document ALL: • E/M Visit • Office Visit, Preventive Medicine • Immunization Administration • 90471 – 90474 • 90465 - 90468 (2005 Peds specific) • Vaccine/Toxoid • 90476 – 90749 • Link to ICD Diagnoses • V20.2 Well Child • Asthma diagnosis • + Specific Vaccine V Codes

21. H1N1 Influenza Coding • CPT • 90470 - H1N1 IA, any route, including counseling $24 • 90465-90468, 90471-90472 – if directed by plan • G9141- H1N1 IA, any route, including counseling Ohio Medicare $19.95 • ICD • 90663 – Influenza vaccine, pandemic formulation • G9142 –Influenza A vaccine (H1N1), any route administration • $0 vs. $0.01 charge

22. H1N1 Influenza Testing Coding • Rapid Influenza testing • If testing for two distinct virus strains (A & B) Report test for rapid influenza test twice 87804 87804-59 (distinct procedure modifier)

23. Non Face-To-Face Physician Services • Telephone Calls • Reviewing Records/Reports • Completing Forms • Managing, Modifying Care Plans • Case Management

24. Telephone ServicesCPT 2008 • 99441 Physician to est patient, parent or guardian 2009 medicare 5 – 10 minutes of medical discussion ($12.62) No related E/M service within previous 7 days No related E/M service in next 24 hours or next available appointment • 99442 11 – 20 minutes ($24.89) • 99443 21 – 30 minutes ($38.33)

25. Non Face-to-Face Non-Physician ServicesCPT 2008 • Telephone – by qualified non-physician health care professional No related E/M service previous 7 days No related other service in next 24 hours or next available appointment 2009 medicare 98966 5 – 10 minutes medical discussion ($12.26) 98967 11 – 20 minutes ($24.89) 98968 21 – 30 minutes ($37.15)

26. Online Medical EvaluationCPT 2008 • 99444 Online E/M service provided by a physician to an est patient, parent, guardian or health care provider Not originating from related E/M service in previous 7 days In response to patient’s online inquiry Using internet or similar communications network Requires “timely response” Permanent storage of encounter ($0.00)

27. Non Face-to-Face Non-physician ServicesCPT 2008 • Online Medical Evaluation • 98969 Online assessment and management, by non-physician health care professional No related assessment and management service in previous 7 days Using internet or similar electronic communication network In response to patient’s on line inquiry ($0.00) Timely response with permanent storage of encounter

28. CSHCNChildren with Special Health Care NeedsCase Management Services Process in which a physician is responsible for direct care of a patient, and for coordinating and supervising other health care services required .

29. Case Management Services (new/revised)CPT 2008 • Medical team conference (99366 – 99368) added • 99366 Direct Contact with Patient and/or Family, 30 minutes or more, non physician participation Physician participation use E/M face to face services • 99367 W/O Direct Contact (Patient and/or Family not present), 30 minutes or more, physician participation • 99368 non physician participation • 99361 – 99362 DELETED

30. Behavior Change Intervention Screening Brief Interventions (SBI) • Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up • Examples: Tobacco and Drug/Alcohol SBI

31. Behavior Change InterventionCPT 2008 • 99406 Smoking and tobacco use cessation counseling visit, 3 – 10 minutes ($12.98) • 99407 > 10 minutes ($24.89)

32. Behavior Change InterventionCPT 2008 • Provided by : Physician or “other qualified health care professional” • E/M Service provided same day must be distinct -25 modifier

33. Provide Consultations !99241-99245 • Payment is 25-42% higher than corresponding new patient office visit codes, and… • Documentation requirements for History, Exam, and MDM are the same! • Consult codes are problem-based and can be used for new or established patients

34. Consultations – 5 R’s - 2008 REASON: Medically necessary REQUEST: By another physician or other appropriate source RENDER: May initiate diagnostic and/or therapeutic services REPORT: By written report back to the requesting source RETURN: Patient back to requesting physician/source

35. Office Consultation/ New or Est

36. 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 service, 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

37. Prolonged Services

38. CODE FOR ASTHMA PROCEDURES !

39. Use HCPCS Codes for Supplies • If not included as standard practice expense for the procedure (Practice expense component of RBRVS) • CPT 99070 General Nonspecific code for supplies • HCPCS codes are preferable Alphanumeric

40. HCPCS Codes Used to report supplies • J1100 - Dexamethasone injection, 1 mg • J0170 - Epinephrine • J0696 - Ceftriaxone, per 250 mg • J7613 - Albuterol for inhalation, 1 unit dose

41. Minor Office Procedures CPT RVU/ 2009 Medicare Aerosol Rx only 94640 0.37/ $13.34 (X-76 for multiple aerosols) Allergy injection (#1) 95115 0.29/ $10.46 #2 or more 95117 0.35/ $12.62

42. Injection / IV Hydration Codes2009 • 90772 → 96372 Therapeutic Injection, Sub Q or IM • 90760 → 96360 IV Infusion, hydration, initial 31 min to 1 hour • 90761 → 96361 IV Infusion, hydration, each add hour

43. Special Services and Reports“Modifier-Like” Codes • 99050 - Services provided inoffice other than regularly scheduled hours normally closed • 99051 - Services provided in office during regularly scheduled evening, weekend, holiday hours • 99053 - Services provided 10PM to 8AM at 24 hour facility • 99058 - Office services on an emergency basis Codes billed in addition to basic service

44. Optimizing Reimbursement Through CPT Coding Utilize Time Time spent in counseling and coordination of care greater than 50% of the visit time Ex: 99213 (15 min) to 99214 (25 min) Asthma requiring extensive counseling Asthma followup visit Document time spent and counseling issues

45. Documentation/ ICD 9 CM • ICD coding should support higher levels of coding (medical necessity) • 99213 to 99214 • Code multiple diagnoses • Document chronic condition when an acute problem is presented • Asthma • Hypoxia

46. Code for extensive medical services • Optimize standard office visit services • Hx, PE, Complexity • Time • $ OV < Prev Med < Consultation • Utilize prolonged services codes • 99354-99359 For excess time spent beyond E/M code

47. DOCUMENT !DOCUMENT !DOCUMENT !

48. *Turn to AAP for Help – State AAP Pediatric Councils SOAPMaap.org PMO

49. AAP Your CODING CONNECTION Coding & Reimbursement Resources • National AAP Coding Hotline: aapcodinghotline@aap.orgor 800/433-9016 ext 4022; free service to members and their office staff • Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner