Billing Basics - Hospitalist Lecture - Ashley Busuttil

7/27/2019 Billing Basics - Hospitalist Lecture - Ashley Busuttil

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Billing Basics

Ashley Busuttil M.D.

Part I

Billing Background

Learning Objectives

Definition of ICD-9 CM codesDefinition of CPT codesMedical Necessity and the interplaybetween diagnosis and coding

Deciphering the Alphabet Soup…

Diagnosis (ICD) versus Service (CPT)

ICD codes are diagnosis codes – Describe new and established

diagnoses – Also include symptom codes – headache (symptom code), vs

migraine (diagnosis code)

Diagnosis (ICD) versus Service (CPT)

CPT codes are service codes – Describe performed services, both

procedures andevaluation/management (E/M)

– Service codes must be based onnecessity determined bydiagnosis/ICD-9 codes

ICD or Diagnosis/DiseaseCodes

International Classification of DiseasesDeveloped by the WHOFacilitates classification of morbidity andmortality data and international diseasestandardizationRevised periodically: – ICD-9 valid 1979-1998 – ICD-10 valid 1999-Present

ICD-9 CM

ICD-9 CM: International Classification of Diseases, 9 th Revision, ClinicalModificationSystem modified from ICD, includes morespecificity for clinical and billing purposesRevised annuallyICD-10 CM currently under testing, maybe in use in coming years.

V Codes (sub set of ICD-9 CM codes)

Code for preventative careUsually not reimbursable themselves,but… May allow for reimbursement of other services not otherwise authorized – HIV, asymptomatic (v08) allows for payment

of vaccines not otherwise reimbursed – Family history, breast cancer (v16.3) allows

for reimbursement of early screening or

genetic testing

CPT Codes/Service Codes

Current P rocedural TerminologyDescribe performed services, bothprocedures and Evaluation andManagement (E/M)Service codes must be based onnecessity determined bydiagnosis/ICD-9 codes

CPT Codes Cont…

Currently the national standard for almost allhealth insurers (Medicare, Medicaid andprivate insurers)

1960’s 1970’s 1983

Developed by AMA tostandardize

billing/coding for Surgical Specialties

Expanded toinclude medical procedures and

services

Adopted andstandardized by

federal government toinclude all

subspecialties

CPT Codes Cont…

5 digit codesCover all billable services and procedures – Anesthesia 00100-01999

– Surgery 10040-69999 – Radiology 70010-79999 – Pathology and Laboratory 80001-89399 – Medications (ie meds administered) 90700-99199 – Evaluation and Management (E/M) 99201-99499

CPT Codes – an example

An 65 yo man visits his PCP for his annual checkup andincidentally complains of 2 days of knee pain. On examhis knee is erythematous, warm, tender and swollen.You perform a joint aspiration, and he also receives aPneumovax as part of his routine preventative care.

3 codes apply (and can all be used for the single visit) – Evaluation and management code – Medication code (for vaccine) – Surgery code (for joint aspiration)

Medical Necessity Rule

There must be a connection between thediagnosis and the corresponding serviceCPT codeMD must decide what is medicallynecessary care for the given diagnosis,and bill accordinglyEven if documentation is extensive, onlybill for medically necessary care

Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statement

“Medical necessity is determined based onthe diagnosis submitted for that service or supply. Specificity and accuracy of diagnosis code and linkage on the claimform determine payment.”

ICD-9CM and CPT

MAKE THE CONNECTION!!!

Part II

Using E&M Codes

The new versus established patientThe three key components of the

document – History – Physical Exam

– Medical decision making

Learning Objectives

Level OutptNew

Outptf/u

InptNew

Inptf/u

1 99201 99211 99221 99231

2 99202 99212 99222 99232

3 99203 99213 99223 992334 99204 99214

5 99205 99215

The New versus Established patient• E&M codes are broken down into inpatient vs outpatient

• Further divided into outpt new vs f/u and inpt new vs f/u

The New versus Established Patient

A “new” patient has had no care by any member of the billing physician’s specialty

and practice group within 3 years.

The New versus Established patient Cont…

You work in a large multispecialty practicegroup. A gastroenterologist in your group,Dr. WW, follows a 50 yo man for IBD. Dr.WW refers him to you to establish primarycare. The patient has never had a primary

care MD before. New or established?

You come to your first continuity clinic on day 1 of your R2 year. You are dismayed to find 5

patients you have never seen before on your schedule, all intending to establish primary care.

They all used to be primary care patients of your senior resident who just graduated and

moved on to a grueling fellowship in pulmonaryand critical care. New or established?

ESTABLISHED

You work in a small group practice in Beverly Hills.You just saw a 55 yo woman who came into

establish new primary care. She used to see

another doctor in your practice but she stoppedseeing him when he was arrested for Medicarebilling fraud 4 years ago. She has not had any

medical care since. New or established?

3 Key Components of theDocument

(follow along you your plastic card from here on…)

(Chief Complaint)History (HPI, ROS, PMH/FH/SH)Physical ExamMedical Decision making (problems, data, risk)

*First encounters - must meet criteria for all 3components for a given billing level

*Follow-up encounters - must meet criteria for only

2 of 3 components for a given billing level

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

CC + + + + +History HPIROS

PMH/FH/SH

N/A 1 1 4 4

N/A 0 1 2 10

N/A 0 0 1 2

PhysicalExam

N/A 1 6 12 in >2systems

2 in eachof 9systems

Med DecisionMakingProblemDataRisk

N/A 1 2 3 4

N/A Minimal Low Moderate

Established Outpatient Visits

A Note on Level 1 billing for outpatient followups…

Ignore it…mostly pertains to nursing

visits, focus on levels 2-5

Chief Complaint

• Not considered one of the “key components”because does not determine which CPT codeyou can use but…

• Required for EVERY level of billing, so ALWAYS include a chief complaint

• Chief complaint of “follow -up” is not sufficient

• Chief complaint of “follow -up” on diabetes issufficient

History

Includes 3 components – HPI – ROS – PMH/FH/SH

HPI Cont…

Refer to card – Brief = 1-3 qualifiers (levels 2-3)Extended = 4+ qualifiers (levels 4-5)

Eg. 65 yo man with cc of abdominal pain. Pain issevere, located in mid-epigastrum, radiates toback, is worsened by food. Also has a rash andurinary frequency.

*Note that “rash and urinary frequency” may notcount as HPI b/c don’t refer to chief complaintabd pain.

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

PMH/FH/SH

N/A 1-3 1-3 4 4

N/A 0 1 2 10

N/A 0 0 1 2

PhysicalExam

N/A 1 2 3 4

N/A Minimal Low Moderate High

HPI Cont…

• Chronic Conditions

Because chronic medical conditions often do not havesymptoms amenable to description through qualifiers, you caninstead document the status of 3 chronic conditions in place of an extended (ie >/= 4 qualifiers) HPI

Eg: A 72 yo male comes in with cc of f/u on hypertension,coronary artery disease and hypercholesterolemia.Documenting the status of each of these as improved, stable or worse can replace the HPI qualifiers

ConstitutionalEyesEars, Nose, MouthThroatCardiovascular

RespiratoryGastrointestinalGenitourinary

MusculoskeletalNeuroSkin and BreastPsychHeme/Lymph

EndocrineImmuno/allergy

14 systems recognized by MediCare

ROS Cont…

Refer to your card – – Problem Pertinent = 1 system (level 3) – Extended = 2-9 systems (level 4) – Complete = >/= 10 systems (level 5)

* Medi-Cal requires 14 systems)

You may use a patient completed checklist for your ROS

You must specifically document that you havereviewed the patient document, and state if it isan “extended” or “complete” ROS

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

PMH/FH/SH

N/A 1 1 4 4

N/A 0 1 2-9 10

N/A 0 0 1 2PhysicalExam

N/A 1 2 3 4

PMH/FH/SH

Past History includes: – Past Medical history – Past Surgical History – Medications

– Allergies – ImmunizationsFamily HistorySocial History

On a followup visit you may refer to a review of prior documentation of the past history

Refer to your card - 1 components = level 4, 2 =

level 5

Remember!!!

To meet a given billing level for the Historykey component, you must document atthat level for EACH of the 3 sub-components, HPI, ROS and PMH

Physical Exam12 recognized organ systems for exam – Constitutional (includes vitals and general appearance) – Eyes – Ears, Nose, Mouth Throat – Cardiovascular – Respiratory – Gastrointestinal – Genitourinary – Musculoskeletal – Skin and/or Breast/Chest

– Neurologic – Psychiatric – Hematologic/lymphaticNote – same as ROS but w/o immunologic or endocrine

Physical Exam Cont…

Some additional tips on the PEExtremities is not an organ system!LE edema is under CVJVP, carotid bruits are CV not neckEOMI is neuro, not eyesGait and strength are part of MSK not neuroOrientation is psych, not neuro

Medicare has a list of accepted elements of examination for each system (review card for details)

Refer to card – – Problem focused = 1-5 elements (level 2) – Problem expanded = 6+ elements (level 3) – Detailed = 12 elements in >/= 2 systems (level 4) – Comprehensive = 2 elements in 9 systems (level 5)

All inpatient H&P should qualify for as“comprehensive”

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

PMH/FH/SH

N/A 1 1 4 4

N/A 0 1 2 10

N/A 1 2 3 4

Each documented “element” within asingle organ system must be of a differentmethod, ie looking vs palpation vsauscultationFor eg: RRR no m/r/g is only one elementwithin the CV system (auscultation only).

No m/r/g with non-displaced PMI is twoelements (auscultation and palpation)

For Subspecialists…

Subspecialists have the option of documenting a detailed single systemexam with multiple elements (thinkorthopedic exam of the knee)

Medical Decision Making

Includes 3 components – Number of Diagnoses/Problems – Data Reviewed – Risk of Conditions and Management

Diagnoses/Problems

Self limited/minor problem (2 max) = 1 pointEstablished prob (stable/improved) = 1 pointEstablished prob (worse) = 2 points

New problem w/o planned w/u = 3 pointsNew problem w/ planned w/u = 4 points

*Billing level is based on point system;comprehensive/level 5 = 4 points

* Remember to document new vs establishedproblems and stability vs improvement/worsening

E bli h d O i Vi i

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

PMH/FH/SH

N/A 1 1 4 4

N/A 0 1 2 10

N/A 1 2 3 4

Data Review

Complexity of data reviewed isdetermined by point system.

Different types of data and differentmeans of reviewing receive differentpoints.

Data Review Cont…

Lab test reviewed 1 pointRadiology test reviewed 1 pointOther diagnostic test reviewed 1 point

Independent review of radiologytest/EKG etc

2 points

Review of test with performing

1 point

Decision/attempt to obtainoutside records

1 point

Review and summary of outside

records

1 point

E t bli h d O t ti t Vi it

Level 199211

Level 299212

Level 399213

Level 499214

Level 599215

PMH/FH/SH

N/A 1 1 4 4

N/A 0 1 2 10

2 ineach of 9systems

Med DecisionMakingProblemData

N/A 1 2 3 4

N/A Minimal Low Moderate High

Determined by AMA guidelines re: – Severity of problem , – Invasiveness of diagnostic procedures/

tests – Risk of medications/treatments

Risk is determined by highest level in any

one category

Ri k C

Risk Cont… Risk Problem Data/Tests Treatments

Low 1 chronic stable problem2 minor problems1 acute non-systemic

problem

ABG/PFT/UGI OTC medsPT/OTMinor surgery w/o RF

Moderate 2 stable chronic1 new prob with unclear

diagnosis1 mild exacerbation

LP/thoracentesisLow risk cathLow risk

endoscopyExcisional bx

IV medicationsPrescription rxMinor surg w/ RFElective major surgery

w/o RF

High Acute or chronic lifethreat prob

Severe exac of chronicprob Acute AMS

Psych risk to self

High risk cathHigh risk

endoscopyEP test

Intense monitoring for drug toxicity (dig levels,heparin, coumadin)

Elective surg w/ RFNew DNR

IV narcotics

Level of MDM

Determined by highest 2 of 3 MDM sub-components (ie problem, data, risk)Note this is different than the Historycomponent when all 3 sub-components(HPI, ROS and PMH) must meet/exceedbilling requirements

Level of MDM Cont…

Problem 0-1 pts 2 pts 3 pts 4 pts

Data 0-1 pts 2 pts 3 pts 4 pts

Risk Minimal Low Moderate High

LevelMDM

Straight-forward

Low Moderate High

Other tips…

Consultations

Consultation request must be documentedby requesting physicianThe name of the requesting physicianmust be documented by the consultingphysicianThere must be documentation of communication back to the requestingphysician

Emergency and Critical Care

If you provide the equivalent of emergencyor critical care you can bill as such – Pt presents to clinic with active chest pain

who you stabilize with NTG, ASA and betablockers and is then sent directly to ED

– Pt on the ward who develops an unstabletachyarrthymia who you cardiovert andotherwise stabilize prior to transfer to MICU

Attending Observation

Attending can use coding modifiers for outpatient visits that they supervise

Attendings must directly supervise allpatients in the following settings: – All new patients – All patients seen by resident in first 6 months

of training – All patients billed >/= level 4

Counseling

If > 50% of patient encounter is spent withface to face counseling, you can bill for counseling timeTotal time with patient and percentage of time spent counseling must bedocumented

Billing Basics - Hospitalist Lecture - Ashley Busuttil

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