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Getting It Right the First Time Coding and Documentation 2013 steve. adams@ingaugehsi. com Steven Getting It Right the First Time Coding and Documentation 2013 steve. [email protected] com Steven Allen Adams

Discussion Points • Incident To • E and M Coding for: Office Visits Pre Discussion Points • Incident To • E and M Coding for: Office Visits Pre operative Consultations • Modifiers E/M Only Surgery Only Global Periods • Preventive Services • Transitional Care Management

Incident To Incident To

Incident To Billing Using MD # 4 standard criteria for Incident To: 1. Physician Incident To Billing Using MD # 4 standard criteria for Incident To: 1. Physician must be in office 2. Must be an established patient 3. Must not change anything from previous plan of care 4. Doctor should see patient every 3 rd or 4 th visit (shows active participation)

E&M Coding E&M Coding

Code Selection Medical necessity of a service is the overarching criterion for payment in Code Selection Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

A Word on “Cloning” Cloning occurs when medical documentation is exactly the same from A Word on “Cloning” Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This “cloned documentation” does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.

Office – Outpatient Services Office – Outpatient Services

Outpatient Visit New / Consults 99201 99245 “Requires All Three Key Elements” Outpatient Visit New / Consults 99201 99245 “Requires All Three Key Elements”

New/Consultation Patient Visits (3 out of 3) Code Minutes 99201 10 99241 15 99251 New/Consultation Patient Visits (3 out of 3) Code Minutes 99201 10 99241 15 99251 20 99202 20 99242 30 99252 40 99203 History 30 CC 1 HPI CC 1 HPI 1 ROS Examination Problem Focused 1995 –(1) 1997 – (1 check) Exp. Problem Focused Detailed 99243 40 99253 Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Straightforward Diagnosis – Minimal Data – Minimal or None Risk – Minimal Diagnosis – Limited Data – Limited Risk – Low OTC, Short-term Meds, Minor Surgery 55 99204 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Decision Making 45 Comprehensive 99244 60 99254 80 99255 110 Diagnosis – Multiple Data – Moderate Risk – Moderate Long term Rx or Major Surgery 60 99245 Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) 80 99205 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Comprehensive CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Diagnosis – Extensive Data – Extensive Risk – High

New Patient Definition A new patient is one who has not received any professional New Patient Definition A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

New Patients – Think: • 99202 – • 99203 – • 99204 – • New Patients – Think: • 99202 – • 99203 – • 99204 – • 99205 – No treatment Short term meds, OTC, minor surgery Long term meds, major surgery Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

Initial Visits New Outpatient Peer Data 54% Dr. Gotcha 45% 31% 27% 4% 99202 Initial Visits New Outpatient Peer Data 54% Dr. Gotcha 45% 31% 27% 4% 99202 6% 5% 6% 99201 22% 1% 99203 99204 99205

Importance of History • Medical necessity of an Evaluation and Management (E/M) encounter is Importance of History • Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements. • Staff can do the past medical history, family history, social history but we expect the provider to do the chief complaint in the history of present illness

Unable To Obtain History The physician should document the reason the patient is unable Unable To Obtain History The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

Normal and Negative For the examine and the review of system(s) related to the Normal and Negative For the examine and the review of system(s) related to the presenting problem - do not describe as "normal" or "negative. "

Other Issues Extended HPI – 4 HPI or Status of 3+ chronic or inactive Other Issues Extended HPI – 4 HPI or Status of 3+ chronic or inactive conditions. Complete ROS (lots of questions on the ROS.

1995 – Comprehensive (8) 1. Const: Vital signs listed above. Well developed, well nourished 1995 – Comprehensive (8) 1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. 2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5. Cardio: RRR, Normal S 1, S 2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6. Respiratory: Chest symmetrical, respirations non labored. No dullness or flatness. Clear bilaterally to auscultation, non tender to palpitation. 7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8. Neurologic: No focal deficits, cranial nerves II XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

What Doesn’t Count (8) - 1995 • Head • Neck • Thyroid • Abdomen What Doesn’t Count (8) - 1995 • Head • Neck • Thyroid • Abdomen • Extremities • Back • Under the 1995 Guidelines CMS and the AMA want you to examine “ORGAN SYSTEMS” and not body areas with regard to any code with the number (8) in the exam criteria

Expanded vs. Extended • The difference is not the number of systems examined. Two Expanded vs. Extended • The difference is not the number of systems examined. Two to seven systems are required for both examinations. • The difference is the detail in which the examined systems are described.

1995 – Detailed 4 -7 (4 x 4) 1. Const: Vital signs listed above. 1995 – Detailed 4 -7 (4 x 4) 1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X’s 3. No mood disorders noted, calm affect. 2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5. Cardio: RRR, Normal S 1, S 2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6. Respiratory: Chest symmetrical, respirations non labored. No dullness or flatness. Clear bilaterally to auscultation, non tender to palpitation. 7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8. Neurologic: No focal deficits, cranial nerves II XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

1997 “Bullet Guidelines” • Allow you to document systems and areas, however you have 1997 “Bullet Guidelines” • Allow you to document systems and areas, however you have to be very specific about what you document about those systems and areas. • Most EMRs are based on the 1997 guidelines but are not compliant

1997 Guidelines - Correct • EYES: [ ] Sclera white, conjunctive clear. Lids are 1997 Guidelines - Correct • EYES: [ ] Sclera white, conjunctive clear. Lids are without lag. [ ] PERRLA. • ENT: [ ] Tympanic membranes translucent, non bulging and mobile. Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink / symmetric. • This would be 5 bullets and compliant

1997 Guidelines – Not Correct • EYES: [ ] Sclera white, [ ]conjunctive clear. 1997 Guidelines – Not Correct • EYES: [ ] Sclera white, [ ]conjunctive clear. Lids are without lag. [ ] PERRLA. • ENT: [ ] Tympanic membranes translucent, non bulging and mobile. [ ] Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink [ ] Lips symmetric. • This would be 8 bullets and not compliant

What To Do • I’ll have a copy of those guidelines posted on my What To Do • I’ll have a copy of those guidelines posted on my web site and I’ll give you a link on medicalofficeblog. com • Make sure that you are only getting credit for what the government says you get credit for documenting. • THIS IS A CRITICAL COMPONENT OF YOUR EMR COMPLIANCE

New Patients – Think: • 99202 – • 99203 – • 99204 – • New Patients – Think: • 99202 – • 99203 – • 99204 – • 99205 – No treatment Short term meds, OTC, minor surgery Long term meds, major surgery Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

Outpatient Visit Established Patient 99211 99215 “Requires Two of Three Key Elements” Outpatient Visit Established Patient 99211 99215 “Requires Two of Three Key Elements”

Established Patients – Think: • 99212 – One stable condition • 99213 – Two Established Patients – Think: • 99212 – One stable condition • 99213 – Two stable or one unstable problem • 99214: 3 chronic stable on meds 2 unstable on meds 1 stable and one unstable on meds • 99215 – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

Established Visits 45% Established Outpatient 43% Peer Data 41% Dr. Gotcha 36% 18% 5% Established Visits 45% Established Outpatient 43% Peer Data 41% Dr. Gotcha 36% 18% 5% 1% 99211 5% 4% 99212 99213 99214 1% 99215

Established Patient Visits (2 out of 3) 99211 N/A N/A Problem Focused 1995 –(1) Established Patient Visits (2 out of 3) 99211 N/A N/A Problem Focused 1995 –(1) 1997 – (1 check) N/A 99212 10 CC 1 HPI Straightforward Diagnosis – Minimal 1 Data – Minimal or None 1 Risk – Minimal 1 1 stable problem 99213 15 CC 1 HPI 1 ROS Exp. Problem Focused Detailed 99214 25 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Comprehensive 99215 40 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Low Diagnosis – Limited 2 Data – Limited 2 Risk – Low 2 2 stable problems 1 unstable problem Diagnosis – Multiple 3 Data – Moderate 3 Risk – Moderate 3 stable problems on meds 1 stable and 1 unstable on meds 2 unstable problems on meds New problem requiring major surg Diagnosis – Extensive 4 Data – Extensive 4 Risk – High 4 High Very sick patient with extensive data review and high risk

Counseling Dominated 3 standard criteria for time: 1. Total Face to Face time of Counseling Dominated 3 standard criteria for time: 1. Total Face to Face time of provider 2. That more than 50% was counseling 3. Topics you discussed “If the level of care is being based on time spent with the patient for counseling/coordination of care documentation should support the time for the visit and the documentation must support in sufficient detail the nature of the counseling”

Signature Requirements • Make sure you properly SIGN all your notes, orders, test results; Signature Requirements • Make sure you properly SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have the provider’s signature. If the provider is initialing this documentation he/she must also print their name by the initials or circle the typed name on an office form. This lets the reviewer clearly see that who documented the medical record.

Established Patients – Think: • 99212 – One stable condition • 99213 – Two Established Patients – Think: • 99212 – One stable condition • 99213 – Two stable or one unstable problem • 99214: 3 chronic stable on meds 2 unstable on meds 1 stable and one unstable on meds • 99215 – Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

Hospital – Inpatient / Outpatient Hospital – Inpatient / Outpatient

Initial Hospital Visits 3 out of 3 Code Minutes History Examination 99221 30 CC Initial Hospital Visits 3 out of 3 Code Minutes History Examination 99221 30 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) 99222 50 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History 99223 70 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Decision Making Straightforward / Low Diagnosis – Minimal Data – Minimal or None Risk – Minimal Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Comprehensive Diagnosis – Multiple Data – Moderate Risk – Moderate Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Comprehensive Diagnosis – Extensive Data – Extensive Risk – High Moderate High Subsequent Hospital Visits 2 out of 3 Problem Focused 99231 15 CC 1 HPI 99232 25 CC 1 HPI 1 ROS 99233 35 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History 99238 30 Hospital Discharge 99239 > 30 Problem Focused 1995 –(1) 1997 – (1 check) Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Hospital Discharge > 30 minutes – {Must document time} Definitions 99221 Admission – Low Risk 99222 Admission – Moderate Risk 99223 Admission – High Risk 99231 Patient is responding well 99232 Pt is responding inadequately to therapy / developed a minor complication 99233 Pt is unstable or has developed a significant complication / significant new problem Straightforward / Low Diagnosis – Minimal Data – Minimal or None Risk – Minimal Diagnosis – Multiple Data – Moderate Risk – Moderate Diagnosis – Extensive Data – Extensive Risk – High Moderate High

Time - 99239 Per Change Request 5794, the Hospital Discharge Day Management Service (CPT Time - 99239 Per Change Request 5794, the Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-toface evaluation and management (E/M) service with the patient and his/her attending physician. Therefore, the time must be spent with the patient.

Observation Coding Observation Coding

Observation/Hospital Discharge Same Day - 3 out of 3 Code Minutes History 99234 40 Observation/Hospital Discharge Same Day - 3 out of 3 Code Minutes History 99234 40 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History 99235 50 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History 99236 55 CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Detailed Examination Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Decision Making Straightforward / Low Diagnosis – Minimal Data – Minimal or None Risk – Minimal Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Diagnosis – Multiple Data – Moderate Risk – Moderate Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Diagnosis – Extensive Data – Extensive Risk – High

Observation - 3 out of 3 (first day of a multiple day observation service) Observation - 3 out of 3 (first day of a multiple day observation service) 99218 Detailed / Comprehensive N/A CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History 99219 N/A CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History 99220 N/A CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Straightforward / Low Diagnosis – Minimal Data – Minimal or None Risk – Minimal Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Diagnosis – Multiple Data – Moderate Risk – Moderate Comprehensive 1995 – (8) 1997 – (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Diagnosis – Extensive Data – Extensive Risk – High

Subsequent Observation Care Visits - 2 out of 3 (day(s) after first till day Subsequent Observation Care Visits - 2 out of 3 (day(s) after first till day before discharge) Problem Focused 99224 15 CC 1 HPI 99225 25 CC 1 HPI 1 ROS 99226 35 CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Exp. Problem Focused Detailed Problem Focused 1995 –(1) 1997 – (1 check) Exp. Problem Focused 1995 – (2 – 7) 1997 – (6 checks) Detailed 1995 – (4 -7 – need 4 x 4) 1997 – (12 checks) Observation Discharge (final day of observation) 99217 N/A Observation care discharge on date other than initial observation day Straightforward / Low Diagnosis – Minimal Data – Minimal or None Risk – Minimal Diagnosis – Multiple Data – Moderate Risk – Moderate Diagnosis – Extensive Data – Extensive Risk – High

The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making documentation in the medical record shall include: 1. Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours; 2. Documentation identifying the billing physician was present and personally performed the services; and 3. Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.

When a patient receives observation care for less than 8 hours on the same When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario.

In the rare circumstance when a patient receives observation services for more than 2 In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

Modifiers Modifiers

Global Period • 0 -10 days = minor ( 25 on E&M) • 90 Global Period • 0 -10 days = minor ( 25 on E&M) • 90 days = major actually 92 days ( 57 on E&M) • MMM = maternity codes • XXX = global concept doesn’t apply (x ray/lab) • YYY = up to carrier (unlisted codes) • ZZZ = always included in global of another service (add on codes)

E&M Only Modifiers • 24 – Unrelated E&M • 25 – E&M and minor E&M Only Modifiers • 24 – Unrelated E&M • 25 – E&M and minor surgery same day • 57 – E&M day before or day of major surgery Use of the 25 modifier means the procedure note is separate from the E&M note

Surgery Only Modifiers • 58 – Anticipated at time of initial procedure • 78 Surgery Only Modifiers • 58 – Anticipated at time of initial procedure • 78 – Related to initial procedure • 79 – Unrelated to initial procedure Use of the 78 modifier means the second procedure will be reduced

E&M and Minor Surgery 78 y/o woman presents to physicians office to have her E&M and Minor Surgery 78 y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck: A. 99213 25, 11200 B. 11200 C. 99213, 11200 25 D. 99213 57, 11200 25

E&M in Global One week later the patient returns for follow up visit for E&M in Global One week later the patient returns for follow up visit for his elevated BP and to have the skin tag sites examined. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and changes the BP medicine and then destroys a pre malignant lesion on the patient’s right forearm. Code for the second visit: A. 99213 24 25, 17000 6 B. 99213 24, 25, 17000 79 C. 17000 D. 99213 25, 17000 51

Preventive Medicine Services Preventive Medicine Services

Prevention Services • CMS is proposing to develop separate Level II HCPCS codes for Prevention Services • CMS is proposing to develop separate Level II HCPCS codes for the first annual wellness visit, to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for the subsequent annual wellness visits, to be paid at the rate of a level 4 office visit for an established patient.

IPPE- Welcome to Medicare 1. 2. 3. 4. 5. 6. 7. Review Medical and IPPE- Welcome to Medicare 1. 2. 3. 4. 5. 6. 7. Review Medical and Social History. Review Risk Factors for Depression and Mood Disorders. Review Functional Ability and Level of Safety. Height, Weight, BP, VA, BMI. End of life Planning If Needed Education, Counseling and Referrals Based on Above Education, Counseling, and Referrals for Other Listed Services

New AWV Codes • G 0438 (Annual wellness visit; includes a personalized prevention plan New AWV Codes • G 0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit); and • G 0439 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit). • We note that practitioners furnishing a preventive medicine E/M service that does not meet the requirements for the IPPE or the AWV would continue to report one of the preventive medicine E/M services CPT codes in the range of 99381 through 99397 as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare. "

In the CY 2011 PFS final rule with comment period (75 FR 73411), we In the CY 2011 PFS final rule with comment period (75 FR 73411), we stated “that when the Health Risk Assessment is incorporated in the AWV, we will reevaluate the values for HCPCS codes G 0438 and G 0439”. As discussed in the CY 2011 PFS final rule with comment period, the services described by CPT codes 99204 and 99214 already include ‘preventive assessment' forms. For CY 2012, we believe that the current payment crosswalk for HCPCS codes G 0438 and G 0439 continue to be most accurately equivalent to a level 4 E/M new or established patient visit; and therefore, we are proposing to continue to crosswalk HCPCS codes G 0438 and G 0439 to CPT codes 99204 and 99214, respectively.

AWV - Initial 1. 2. 3. 4. 5. 6. 7. 8. 9. Health Risk AWV - Initial 1. 2. 3. 4. 5. 6. 7. 8. 9. Health Risk Assessment Establishment of an individual's medical and family history. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual. Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. Detection of any cognitive impairment that the individual may have. Review of the individual's potential (risk factors) for depression, Review of the individual's functional ability and level of safety, based on direct observation Establishment of the following: ++ A written screening schedule, such as a checklist, for the next 5 to 10 years ++ A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended. Furnishing of personalized health advice to the individual and a referral, as appropriate. Any other element determined appropriate through the National Coverage Determination process.

AWV - Subsequent 1. 2. 3. 4. 5. 6. 7. Health Risk Assessment An AWV - Subsequent 1. 2. 3. 4. 5. 6. 7. Health Risk Assessment An update of the individual's medical and family history. An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing personalized prevention plan services. Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. Detection of any cognitive impairment, as that term is defined in this section, that the individual may have. An update to both of the following: ++ The written screening schedule for the individual as that schedule was developed at the first AWV providing personalized prevention plan services. CMS 1503 FC 761 ++ The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV providing personalized prevention plan services. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined in paragraph (a) of this section. Any other element determined through the NCD process.

Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Pt. Received An Initial AWV From Medicare Yes G 0439 No G 0438

Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Pt. Received An Initial AWV From Medicare Yes G 0439 No G 0438

Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Pt. Received An Initial AWV From Medicare Yes G 0439 No G 0438

Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Has Pt. Had Medicare for More than 12 Months Yes No G 0402 Has Pt. Received An Initial AWV From Medicare Yes G 0439 No G 0438

Breast / Pelvic Exam The HCPCS Code: • G 0101 – Pelvic and Breast Breast / Pelvic Exam The HCPCS Code: • G 0101 – Pelvic and Breast Exam The Diagnosis Codes V 72. 31 Routine gynecological exam V 76. 47 Screening for neoplasm of the vagina V 76. 49 Screening of woman without a cervix V 76. 2 Screening for neoplasm of cervix V 15. 89* - Every Year Presenting health hazards

Four Questions CERVICAL CANCER HIGH RISK SURVEY Was your first sexual activity prior to Four Questions CERVICAL CANCER HIGH RISK SURVEY Was your first sexual activity prior to the age of 16? Yes No Have you had more than 5 sexual partners? Yes No Do you have a history of sexually transmitted disease (including HIV) infection? Yes No Have you had fewer than 3 negative pap smears within the previous seven years? Yes No

Exam Required Female G/U: (7 of the following 11) Breasts symmetrical. No masses, lumps, Exam Required Female G/U: (7 of the following 11) Breasts symmetrical. No masses, lumps, tenderness, dimpling or nipple discharge. Rectal exam exhibits even sphincter tone, no hemorrhoids or masses. Pelvic No external lesions. Normal hair distribution. Urethral meatus pink, no lesions or discharge. Urethra intact, no tenderness, masses, inflammation or discharge. Bladder without tenderness or masses, no incontinence. Vaginal mucosa moist and pink, without lesions or discharge. Cervix pink, no lesions, odor, or discharge. Uterus midline, non tender, firm and smooth. No adnexal masses, nodules or tenderness. Anus and perineum intact. ___ No lesions, rashes, fissures, fistulas or external hemorrhoids. Wet Prep _________ Hemoccult Pos. Neg.

Obtain Pap Smear The HCPCS Code: • Q 0091 Obtaining screen pap smear The Obtain Pap Smear The HCPCS Code: • Q 0091 Obtaining screen pap smear The Diagnosis Codes V 72. 31 Routine gynecological exam V 76. 47 Screening for neoplasm of the vagina V 76. 49 Screening of woman without a cervix V 76. 2 Screening for neoplasm of cervix V 15. 89* - Every Year Presenting health hazards

Tobacco Cessation Codes The CPT Codes: • 99406: Smoking and tobacco cessation counseling; intermediate, Tobacco Cessation Codes The CPT Codes: • 99406: Smoking and tobacco cessation counseling; intermediate, greater than 3 minutes, up to 10 minutes, • 99407: Smoking and tobacco cessation counseling; intensive, greater than 10 minutes, The Diagnosis Codes • Medical dx of the patient at the time of the visit the tobacco is affecting • If used with E/M, don’t forget modifier 25

New Tobacco Cessation Codes The HCPCS Codes: • G 0436: Smoking and tobacco cessation New Tobacco Cessation Codes The HCPCS Codes: • G 0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, • G 0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, The Diagnosis Codes • ICD 9 code 305. 1 (non dependent tobacco use disorder), or • ICD 9 code V 15. 82 (history of tobacco use).

Home Health Certification The HCPCs Codes: • G 0179 – Re-certification for Medicare-covered home Home Health Certification The HCPCs Codes: • G 0179 – Re-certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care … • G 0180 - Certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care …

Home Health Certification Content of the Physician's Certification • The home health services are Home Health Certification Content of the Physician's Certification • The home health services are because the individual is confined to his/her home and needs intermittent skilled nursing care (other than solely for venipuncture for the purposes of obtaining a blood sample), physical therapy and/or speech language pathology services, or continues to need occupational therapy; • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; (next slide) • The services are or were furnished while the individual was under the care of a physician. • The need for skilled oversight of unskilled services (management and evaluation of the care plan). The physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification or as a signed addendum to the certification and recertification.

Home Health Certification Content of the Plan of Care Signed by Physician • • Home Health Certification Content of the Plan of Care Signed by Physician • • • • The patient's mental status; The types of services, supplies, and equipment required; The frequency of the visits to be made; Prognosis; Rehabilitation potential; Functional limitations; Activities permitted; Nutritional requirements; All medications and treatments; Safety measures to protect against injury; Instructions for timely discharge or referral; and Any additional items the HHA or physicians choose to include. The physician who signs the plan of care must be the same physician to sign the physician certification.

Home Health Certification Time Frame Requirements • The encounter must occur no more than Home Health Certification Time Frame Requirements • The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care. Encounter Documentation Requirements • The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.

Care Plan Oversight The HCPCS Codes: • G 0181 – Supervision of patient receiving Care Plan Oversight The HCPCS Codes: • G 0181 – Supervision of patient receiving Medicarecovered home health agency requiring complex multidisciplinary care… 30 minutes or more • G 0182 - Supervision of patient receiving Medicareapproved hospice care requiring complex multidisciplinary care… 30 minutes or more

CMS and TCM • 99495 Transitional Care Management Services with the following required elements: CMS and TCM • 99495 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of at least moderate complexity during the service period. Face to face visit, within 14 calendar days of discharge. • 99496 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of high complexity during the service period. Face to face visit, within 7 calendar days of discharge.

Discussion Points • Incident To • E and M Coding for: Office Visits Pre Discussion Points • Incident To • E and M Coding for: Office Visits Pre operative Consultations • Modifiers E/M Only Surgery Only Global Periods • Preventive Services • Transitional Care Management

Questions? Questions?

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