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B4: Crack the Code: Addressing Billing Code Issues Laura Brey, Training Director, NASBHC [email protected] 919-866-0920. Welcome and Expectations. Objectives. The Participant will be able to Define CPT, ICD 9, and DSM 4 Coding

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B4: Crack the Code:

Addressing Billing Code Issues

Laura Brey, Training Director, NASBHC

[email protected]



The Participant will be able to

  • DefineCPT, ICD 9, and DSM 4 Coding
  • Explainthe reasons why appropriate coding and documentation is so important in SBHC settings.
  • Demonstratecorrect use of CPT and ICD 9 codes
  • Explainthe rational for conducting routine medical record review and coding compliance audits in SBHC settings
coding definition
Coding Definition
  • Coding is an alphanumeric system used to translate medical procedures and services into data
types of coding
Types of Coding
  • Current Procedural Terminology (CPT)
  • International Classification of Diseases (ICD-9 Clinical Modification - CM)
  • Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)
coding is medicare drive
Coding is Medicare Drive
  • Pediatrics was not considered in original coding guidelines, so some of the things we do in SBHCs may not fit well
sbhc coding
SBHC Coding
  • There is no difference between coding in a SBHC and any other setting – the coding assumptions are the same.
  • You provide the same level of care regardless of the location.
why code correctly
Why Code Correctly?
  • Reimbursement depends on it.
  • Codes describe the services you provide
  • Codes justify these services
  • Services not documented “never happened”

PS: Never code for the purpose of getting more money

the coding process has 2 parts
The Coding Process has 2 Parts

1. “What you did” = CPT

2. “Why you did it” = ICD-9 or DSM-4 TR


a what and a why


when a provider is under coding they tell the wrong story
When a provider is under-coding they tell the wrong story

This wrong story is:

  • SBHC Providers are seeing very few patients with multiple problems.
  • SBHC Providers should see more patients since they are not seeing complicated patients.
  • The SBHC should decrease the number of physicians and add more mid-level providers.
there are two coding guidelines 1995 1997
There Are Two Coding Guidelines - 1995 & 1997
  • Both 1995 and 1997 guidelines are approved for use by CMS
  • Agencies may specify use of 1995 or 1997 guidelines
  • 1997 guidelines are more specific than 1995 in the examination portion (they are more computer friendly)
  • New guidelines have been proposed, but have not yet been accepted
coding guidelines 1995 vs 1997
Coding Guidelines 1995 vs. 1997

This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version.

  • Intentional deception or misrepresentation
    • Deliberately billing for services not performed
    • Unbundling of services
    • Intentionally submitting duplicate claims
  • Improper billing practices
    • Billing for non-covered services
    • Misusing codes on a claim form
Accept it, you will make them.

Your best defense is having a plan for your coding and being able to explain it.

over coding and under coding
Over-coding and Under-coding
  • CPT and ICD-9 codes must always relate
  • The first ICD-9 code you use drives the relationship to the CPT code
cpt codes document
CPT Codes document:
  • Level of Service
  • Procedures Provided
examples of cpt codes
Examples of CPT codes

Evaluation & Management















icd 9 and dsm4 codes document
ICD-9 and DSM4 Codes document:

The reason behind the visit

(They must support the CPT codes)

general coding principles
General Coding Principles
  • Coding gets you paid for your services
  • Coding can be used to justify the need for services to your funders
coding with icd 9
Coding with ICD-9
  • ICD-9 codes have 3, 4 or 5 digits
    • The greater the number of digits, the higher the specificity
      • Use a 5-digit code when it exists
      • Use a 4-digit code only if there is no 5-digit code with the same category
      • Use a 3-digit code only if there is no 4-digit code within the same category

PS: Omitting the required 4th or 5th digit will result in the denial of a claim. Do not add any additional digits, even zero

icd 9 cm codes
ICD-9-CM Codes

Range from 001.0 to V82.9

  • They identify:
    • Diagnoses
    • Symptoms
    • Conditions
    • Problems
    • Complaints
    • Other reason for the procedure, service, or supply provided
icd 9 cm codes27
ICD-9-CM Codes
  • Three volumes
    • Volume 1 Tabular List of Diseases
      • Notes all exclusive terms and 5th-digit instructions
    • Volume 2 Alphabetic Index of Diseases
      • Does not contain detail – Do Not code from this volume
    • Volume 3 Procedures
      • Used almost exclusively for hospital services

PS: (All 3 Volumes are generally found in one binding)

v codes
“V” Codes
  • For circumstances other than disease or injury
  • Three categories:
    • Problem – Could affect overall health status, but is not a current illness or injury
      • Ex.: V14.2 Personal history of allergy to sulfonamines
    • Service – Circumstances other than illness or injury
      • Ex.: V68.1 Issue of a repeat prescription
    • Factual – Certain facts that do not fall into the “problem” or “service” categories
v codes29
“V” Codes
  • Can be used as a:
    • Solo Code
    • Principal code
    • Secondary code
  • May represent check-ups, screenings, administrative requests, prescription refills
determine type of office visit
Determine Type of Office Visit
  • Evaluation and Management

New Patients vs. Established Patients

  • Preventive Health Visits

New Patients vs. Established Patients

  • Counseling Visits

Medical Visit – talker only

  • Mental Health Visits

New Patients vs. Established Patients

determine medical necessity
Determine Medical Necessity
  • Services are reasonable and necessary for the diagnosis and treatment of illness or injury.
  • All payors define necessity differently
  • Clinical rationale must be documented through coding.
  • You cannot write more, to get paid more.
determine chief complaint
Determine Chief Complaint
  • The reason for the patient’s visit
    • S of a SOAP note
  • Codes used must relate to chief complaint or they are invalid
  • And, the chief complaint must be documented in the chart
evaluation management e m services
Evaluation/Management (E / M) Services
  • Used for acute care visits
  • Five levels of service
  • Seven components within the levels
    • Key components – history, exam and medical decision making
    • Contributory components – counseling, coordination of care, nature of presenting problem, and time
evaluation management e m services35
Evaluation/Management (E / M) Services
  • Beginning information about coding deals with the three key components:
    • History
    • Examination
    • Medical Decision Making
evaluation management e m services36
Evaluation/Management (E / M) Services

There are 5 Levels of service

  • Minimal
  • Self-Limited or Minor
  • Low Severity
  • Moderate Severity
  • High Severity
cpt codes used for e m visits
New Patients

Level 1 99201

Level 2 99202

Level 3 99203

Level 4 99204

Level 5 99205

Established Patients






CPT Codes Used for E/M Visits
coding steps39
Coding Steps
  • First Step- Determine if your patient is:

A New Patient


An Established Patient

definition of a new patient
Definition of a new patient:
  • It is the patient’s first visit to the provider
  • The patient has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.

PS: Any time a patient is seen in an Emergency Room they are considered a new patient

if your patient does not meet the definition of a new patient then they are an established patient
If your patient does not meet the definition of a New Patient, then they are an Established Patient
coding steps42
Coding Steps
  • Second Step - determine the level of service for the visit,

To do this you need to determine the level of service for each key component separately

There are 3 key components

They are:

1. History (HPI, ROS, PFSH)

2. Examination

3. Medical Decision Making

coding steps43
Coding Steps

New Patients

  • Within the 3 key components, there are 5 levels of service
  • Remember to Consider the Key Components separately:
    • HPI, ROS, PFSH
    • Examination
    • Medical Decision Making
Example - New PatientThe Level of Service for a new patient visit is determined by the lowest level of service (1 through 5) of the three key components
coding steps45
Coding Steps

Established Patients

  • Again Consider the Key Components Separately:
    • HPI, ROS, PFSH
    • Examination
    • Medical Decision Making
  • The level of service (1 – 5) is determined by the level that appears in 2 of the three components, or by the middle level
How to Steps of Coding: Determine Level of Medical Decision MakingDetermine Level of History ComponentDetermine Level of Physical Examination(You will need to reference the chart – examination notes for this)
determine level of medical decision making
Determine Level of Medical Decision Making
  • Medical Decision Making consists of three sections:
    • Diagnosis or Management Problems
    • Diagnostic Procedures
    • Treatment of Management Options
  • Level is determined by the level found in two of the three categories – or the middle number if all three are different
determine level of medical decision making section i diagnosis or management of problems
Determine Level of Medical Decision Making Section I: Diagnosis or Management of Problems
how to steps of coding determine level of history component
How to Steps of Coding: Determine Level of History Component
  • History component consists of three sections:
    • History of Present Illness (HPI)
    • Review of Systems (ROS)
    • Patient, Family, and Social History (PFSH)
determine level of history component section i history of present illness
Determine Level of History ComponentSection I: History of Present Illness
  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms
determine level of history component section ii review of systems
Determine Level of History ComponentSection II: Review of Systems
  • Constitutional symptoms (fever, wt loss, etc.)
  • Eyes
  • Ears, nose, mouth, throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurologic
  • Psychiatric
  • Endocrine
  • Hematologic/lymphatic
  • Allergic/immunologic
determine level of history component section iii patient family and social history
Determine Level of History ComponentSection III: Patient, Family and Social History
  • Past medical history
    • Medication allergies
  • Patient’s family history
  • Patient’s social history
    • Age-appropriate review of past and current activities
      • Tobacco usage
how to of coding steps determine level of physical examination
How to of Coding Steps: Determine Level of Physical Examination
  • Constitutional
  • Eyes
  • Ears, Nose, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/Lympatic/Immunologic
coding exercise for evaluation management services
Coding Exercise for Evaluation/ Management Services

Suzy Q is a 16 y/o female with c/o

severe “female” cramps - worse than usual.

She states she took Midol and it only

helped a little. She is a new patient.

Document on the exam and encounter

form to a level 3, using audit sheet

as reference.

count the components
Count the components

HRI 1 - Midol

ROS 1 - cramps

PFSH - 0


Level 3

Exam 1-const





Level 3

Med Decision

- acute/uncomp

- OTCs


Level 3

cpt codes used for counseling education only e and m visits
New Patients

10 minutes 99201

20 minutes 99202

30 minutes 99203

45 minutes 99204

60 minutes 99205

Established Patients

5 minutes 99211

10 minutes 99212

15 minutes 99213

25 minutes 99214

40 minutes 99215

CPT Codes Used for Counseling/Education Only E and M Visits
preventive services72
Preventive Services
  • These visits include a comprehensive history and examination, as well as appropriate counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of age-appropriate laboratory/diagnostic procedures.
preventive services73
Preventive Services
  • “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination.
preventive services75
Preventive Services

Appropriate ICD-9 codes would be:

  • V20.2 for a Routine Infant or Child Health Check
  • V70.3 for a Sports Physical
preventive services76
Preventive Services
  • Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately:
    • Examples:
      • Snellen Test
      • Laboratory
      • Immunizations
      • Administration of Immunizations
coverage issues
A provider should know what services are covered.

Services must be documented and medically necessaryin order for payment to be made.

Do you, as a provider, know if all services provided are covered?

Are you documenting properly, and what about this “medically necessary” bit?

Coverage Issues
how much are you paid
How Much are you Paid?
  • Reimbursement
    • Reductions in reimbursement rates by provider type
      • Physician - not discounted
      • NP or PA - sometimes discounted
      • Clinical Psychologist - discounted
      • LCSW - further discounted
      • Other - discounted if covered
reimbursement issues
Reimbursement Issues
  • E&M codes are limited to physicians, PAs, NPs, nurses
  • Same is true for 90805, 90807, 90809 codes
  • An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs
documentation and coding fraud and abuse
Documentation and Coding:Fraud and Abuse
  • Services MUST be medically necessary (determined by payers based on a review of services billed)
  • Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.
  • Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider
elements of incident to
Elements of “Incident To”
  • An integral part of the physician’s professional service
  • Commonly rendered without charge or generally not itemized separately in the physician’s bill
  • Of a type that are commonly furnished in physician’s office or clinic
  • Furnished under the physician’s direct personal supervision
about time with the patient
About Time With the Patient
  • Do not base your level of service on time spent with patient.
  • Time only comes into play if you are billing for counseling within an acute visit or if all you are doing is counseling
sports physicals
Sports Physicals
  • They are not meant to be comprehensive physicals – their focus is different
  • Check www.aap.orgfor an appropriate form
  • You can bill for a complete PE and a sports PE within the same year
counseling visits
Counseling Visits

Counseling visits are when client comes in to discuss a problem only. No hands are laid on the patient.

example dietary surveillance counseling
ExampleDietary Surveillance & Counseling

There must be a dietary problem in order to justify this code.