CPT & ICD-9 CODINGCPT & ICD-9 CODING

Debra Dockter NP-BCDebra Dockter NP-BC

Objective of CodingObjective of Coding

ProviderProvider

- To prepare a standardized “bill” for services - To prepare a standardized “bill” for services

given to a patient.given to a patient. PayerPayer

- To determine the amount to be paid to the - To determine the amount to be paid to the

provider.provider.

DefinitionDefinition

CPT (current procedural terminology) Codes -CPT (current procedural terminology) Codes - are numbers assigned to every task & service a are numbers assigned to every task & service a

medical practitioner may provide to a patient.medical practitioner may provide to a patient. includes: medicalincludes: medical surgicalsurgical diagnostic servicesdiagnostic services **Used by insurers to determine the amount Used by insurers to determine the amount

of reimbursement a practitioner will receive of reimbursement a practitioner will receive from the insurance company.from the insurance company.

CPT CodesCPT Codes

Developed, maintained, and copyrighted by Developed, maintained, and copyrighted by AMA (American Medical Association)AMA (American Medical Association)

New codes are developed for new services,New codes are developed for new services,

current codes may be revised, & old unused current codes may be revised, & old unused codes are discarded codes are discarded annually.annually.

**The exception: Medicare patientThe exception: Medicare patient

CPT CodesCPT Codes

ExamplesExamples

99201 a physical exam99201 a physical exam

90658 flu vaccination90658 flu vaccination

90716 chicken pox vaccine (varicella)90716 chicken pox vaccine (varicella)

12002 laceration repair 12002 laceration repair

*Service reimbursement will vary according to *Service reimbursement will vary according to medical provider and insurance company. medical provider and insurance company.

3 Key Components for CPT 3 Key Components for CPT CodingCoding

Necessary components needed for billing a Necessary components needed for billing a patient visit :patient visit :

* History of problem(s)* History of problem(s)

* Exam related to problem(s)* Exam related to problem(s)

* Medical Decision* Medical Decision These components are determined by:These components are determined by:

Evaluation & Medical Decision MakingEvaluation & Medical Decision Making

*Great resource: *Great resource: www.fpnotebook.comwww.fpnotebook.com

Evaluation & Medical Decision MakingEvaluation & Medical Decision Making

The levels of E & M services are based on 4 The levels of E & M services are based on 4 types of examinations:types of examinations:

Problem FocusedProblem Focused Expanded Problem Focused Expanded Problem Focused DetailedDetailed ComprehensiveComprehensive

Patient Criteria for E/MPatient Criteria for E/M

I. Patient Type: I. Patient Type: NewNew

No professional services in the last 3 years.No professional services in the last 3 years.

II.II. Patient Type: Patient Type: EstablishedEstablished

Maintained professional services in the last 3 Maintained professional services in the last 3 years.years.

Billing for Problem Focus VisitBilling for Problem Focus Visit

Problem Focus Visit – presenting problem self Problem Focus Visit – presenting problem self limited or minor, the provider will spend 10 limited or minor, the provider will spend 10 minutes face to face with the patient and/or minutes face to face with the patient and/or family.family.

New patient visit New patient visit CPT 99201CPT 99201

Established visit Established visit CPT 99211CPT 99211

Billing for Expanded Problem FocusBilling for Expanded Problem Focus

Expanded Problem Focus – presenting Expanded Problem Focus – presenting problem low to moderate severity, provider problem low to moderate severity, provider spends 15 minutes face to face with patient.spends 15 minutes face to face with patient.

New patientNew patient CPT 99202CPT 99202

Established patientEstablished patient CPT 99213CPT 99213

Billing for DetailedBilling for Detailed

Detailed – usually the presenting problem(s) Detailed – usually the presenting problem(s) are moderate to high severity & physical are moderate to high severity & physical assessment typically 25 minutes face to face assessment typically 25 minutes face to face with the patient.with the patient.

New patient New patient CPT 99203CPT 99203

Established patientEstablished patient CPT 99214CPT 99214

Billing for ComprehensiveBilling for Comprehensive

Comprehensive – high complexity, multi-Comprehensive – high complexity, multi-system exam or complete exam of a single system exam or complete exam of a single organ system, lasting 40 minutes.organ system, lasting 40 minutes.

New patient visit CPT 99204New patient visit CPT 99204 Established patient visit CPT 99215Established patient visit CPT 99215

E/M Coding: Level of VisitE/M Coding: Level of Visit

CPT Code History Exam Management Time

99211 Minimal Minimal Minimal 5 minutes

99212 Problem focused

Problem focused

Straightforward 10 minutes

99213 Expanded problem focused

Expanded problem focused

Low complexity

15 minutes

99214 Detailed Detailed Moderate complexity

25 minutes

99215 Comprehensive Complex High complexity

40 minutes

E & M Visit: Elements/BulletsE & M Visit: Elements/Bullets

Female exam consists of 11 elements Female exam consists of 11 elements ––

- Inspection & palpation of breasts- Inspection & palpation of breasts

- Digital rectal exam- Digital rectal exam

- Pelvic exam- Pelvic exam

- External genitalia - Cervix- External genitalia - Cervix

- Urethral meatus - Uterus- Urethral meatus - Uterus

- Bladder - Adnexa- Bladder - Adnexa

- Vagina - Anus & perineum - Vagina - Anus & perineum

E/M Visit: Physical ExaminationE/M Visit: Physical Examination

LEVEL SINGLE ORGAN SYSTEM EXAM

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

1-5 bullet elements

6 or more bullet elements

12 or more bullet elements

Female GU exam, abdomen, constitutional, & other organs

ICD CodesICD Codes

DefintionDefintion ICD (International Statistical Classification of Disease) are alphanumeric ICD (International Statistical Classification of Disease) are alphanumeric

designations given to every diagnosis and description of symptoms!designations given to every diagnosis and description of symptoms!

Describes Describes whywhy that service was provided. that service was provided.

*Remember the *Remember the CPT codeCPT code describes the service that was describes the service that was rendered for billing purposes.rendered for billing purposes.

IDC-9 codes most commonly used codes, ICD-10 transition is very expensive, & IDC-9 codes most commonly used codes, ICD-10 transition is very expensive, & most providers have not yet upgraded to the ICD-10 system.most providers have not yet upgraded to the ICD-10 system.

IDC-11, the next major update ( in the development).IDC-11, the next major update ( in the development).

ICD CodesICD Codes

Diagnostic CodesDiagnostic Codes – identifies diseases, – identifies diseases, disorders, human response, & medical signs.disorders, human response, & medical signs.

ExampleExample Dx of GERD (acid reflux) code Dx of GERD (acid reflux) code 530.81530.81

ICD-CM Coding RulesICD-CM Coding Rules

List the principal diagnosis firstList the principal diagnosis first If diagnosis is not established, code for If diagnosis is not established, code for

symptomsymptom

-Don’t code for “rule-out” diagnosis-Don’t code for “rule-out” diagnosis Don’t code a diagnosis that doesn’t apply to Don’t code a diagnosis that doesn’t apply to

the present visit.the present visit. Preventive E/M codes linked to V codes.Preventive E/M codes linked to V codes.

What are V-Codes?What are V-Codes?

Specific ICD-9 codes used to identify encounters Specific ICD-9 codes used to identify encounters for reasons other than illness or injury.for reasons other than illness or injury.

ExamplesExamples CPTCPT ICD-9 descriptionICD-9 description

Start OCs V 25.01 prescriptionStart OCs V 25.01 prescription

IUC insertion V 25.11 Insertion of IUCIUC insertion V 25.11 Insertion of IUC

Missing string V 45.51 Presence of stringMissing string V 45.51 Presence of string

STI evaluation V 01.6 Contact/exposureSTI evaluation V 01.6 Contact/exposure

Pregnancy test V72.41 Test/exam-negativePregnancy test V72.41 Test/exam-negative

Case Study “Screen Me For Case Study “Screen Me For Everything”Everything”

28 y/o established fe request for STI 28 y/o established fe request for STI screening….asymptomaticscreening….asymptomatic

Monogamous relationship 4 months ago; Monogamous relationship 4 months ago; unprotected sex with new partner 6 wks agounprotected sex with new partner 6 wks ago

Pelvic exam negative; CT, GC, wet prepPelvic exam negative; CT, GC, wet prep Wet prep negative, vaginal pH: 4.0Wet prep negative, vaginal pH: 4.0 Blood drawn for HIV, VDRL, Hepatitis B, Blood drawn for HIV, VDRL, Hepatitis B,

Hepatitis CHepatitis C

Case Study: AnswerCase Study: AnswerCPT code ICD-CM code

ProcedureSuppliesDrugLab

E/M

Modifier

NoneNoneNone87210 (microscopy)83986 (vaginal pH)

99203

None

V01.6 (STI exposure)or V69.2 (HRSB*)

V01.6 (STI exposure)or V69.2 (HRSB*)

*HRSB: high risk sexual behavior

*Unnecessay tests Hep B,C

IN SummaryIN Summary Coding is:Coding is:

ComplexComplex

Hard to rememberHard to remember

BoringBoring

But:But:

- It is how you are credited for the work you do- It is how you are credited for the work you do

- It is often a determinant of how you are paid- It is often a determinant of how you are paid

- It is how fee-for-service is paid- It is how fee-for-service is paid

Therefore, DO IT WELLTherefore, DO IT WELL

Improve Your CodingImprove Your Coding

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Review coding issues & new developments at Review coding issues & new developments at staff meetings.staff meetings.

Coding ResourceCoding Resource ACOG web site: ACOG web site: www.acog.org

- Quick Link - Coding- Quick Link - Coding