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7/27/2019 Billing Basics - Hospitalist Lecture - Ashley Busuttil
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Billing Basics
Ashley Busuttil M.D.
7/27/2019 Billing Basics - Hospitalist Lecture - Ashley Busuttil
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Part I
Billing Background
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Learning Objectives
Definition of ICD-9 CM codesDefinition of CPT codesMedical Necessity and the interplaybetween diagnosis and coding
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Deciphering the Alphabet Soup…
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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)
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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
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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
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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.
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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
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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
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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
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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
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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)
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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
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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.”
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ICD-9CM and CPT
MAKE THE CONNECTION!!!
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Part II
Using E&M Codes
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The new versus established patientThe three key components of the
document – History – Physical Exam
– Medical decision making
Learning Objectives
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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
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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.
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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?
NEW
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The New versus Established patient Cont…
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
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The New versus Established patient Cont…
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?
NEW
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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
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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 1 2 3 4
N/A Minimal Low Moderate
High
Established Outpatient Visits
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A Note on Level 1 billing for outpatient followups…
Ignore it…mostly pertains to nursing
visits, focus on levels 2-5
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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
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History
Includes 3 components – HPI – ROS – PMH/FH/SH
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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.
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Level 199211
Level 299212
Level 399213
Level 499214
Level 599215
CC + + + + +History HPIROS
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 6 12 in >2systems
2 in eachof 9systems
Med DecisionMakingProblemDataRisk
N/A 1 2 3 4
N/A 1 2 3 4
N/A Minimal Low Moderate High
Established Outpatient Visits
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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
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ROS
ConstitutionalEyesEars, Nose, MouthThroatCardiovascular
RespiratoryGastrointestinalGenitourinary
MusculoskeletalNeuroSkin and BreastPsychHeme/Lymph
EndocrineImmuno/allergy
14 systems recognized by MediCare
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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
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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 2-9 10
N/A 0 0 1 2PhysicalExam
N/A 1 6 12 in >2systems
2 in eachof 9systems
Med DecisionMakingProblemDataRisk
N/A 1 2 3 4
N/A 1 2 3 4
N/A Minimal Low Moderate
High
Established Outpatient Visits
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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
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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
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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
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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)
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Physical Exam Cont…
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”
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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 2PhysicalExam
N/A 1 6 12 in >2systems
2 in eachof 9systems
Med DecisionMakingProblemDataRisk
N/A 1 2 3 4
N/A 1 2 3 4
N/A Minimal Low Moderate
High
Established Outpatient Visits
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Physical Exam Cont…
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)
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Physical Exam Cont…
For Subspecialists…
Subspecialists have the option of documenting a detailed single systemexam with multiple elements (thinkorthopedic exam of the knee)
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Medical Decision Making
Includes 3 components – Number of Diagnoses/Problems – Data Reviewed – Risk of Conditions and Management
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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
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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 2PhysicalExam
N/A 1 6 12 in >2systems
2 in eachof 9systems
Med DecisionMakingProblemDataRisk
N/A 1 2 3 4
N/A 1 2 3 4
N/A Minimal Low Moderate
High
Established Outpatient Visits
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Data Review
Complexity of data reviewed isdetermined by point system.
Different types of data and differentmeans of reviewing receive differentpoints.
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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
MD
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
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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 2PhysicalExam
N/A 1 6 12 in >2systems
2 ineach of 9systems
Med DecisionMakingProblemData
Risk
N/A 1 2 3 4
N/A 1 2 3 4
N/A Minimal Low Moderate High
Established Outpatient Visits
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Risk
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
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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
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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
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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
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Other tips…
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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
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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
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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
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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