Coding A Day in the Life of a

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Coding A Day… in the Life of a BUSY Pediatrician 2010 Richard H. Tuck, MD, FAAP

What’s New for 2010 ? • CODES New CPT/ICD Codes • VALUE-RBRVS – New RVU’s and CF • PAYER PAYMENTAAP Private Sector Advocacy Program State Pediatric Councils National Class Action Law Suits • PATIENTSCovered Benefit Consumer Driven Health Care • YOUR CONTRACT- Pay for Performance

CODING CHANGES 2010

ICD-9 -CM 2010 Effective October 1, 2009 New Codes • 756. 72 • 756. 73 Omphalocele Gastroschisis • 768. 70 Hypoxic-ischemic encephalopathy, unspecified Mild Moderate Severe • 768. 71 • 768. 72 • 768. 73

ICD-9 -CM 2010 Effective October 1, 2009 New Codes • • • 779. 31 779. 32 779. 33 779. 34 789. 7 799. 82 Feeding problems in newborn Bilious vomiting newborn Other vomiting in newborn Failure to thrive in newborn Colic Apparent life threatening event in infant

ICD-9 -CM 2010 Effective October 1, 2009 New Codes • • 799. 21 799. 22 799. 23 799. 24 • 832. 2 Nervousness Irritability Impulsiveness Emotional Lability Nursemaid’s elbow

ICD-9 -CM 2010 Effective October 1, 2009 New V Codes • • V 15. 83 V 20. 31 V 20. 32 V 60. 81 Personal history of underimmunization status Health supervision for newborn under 8 days Health supervision for newborn 8 to 28 days Foster care (status)

ICD-9 -CM 2010 Effective October 1, 2009 New V Codes • Family disruption code additions: – V 61. 97 Due to death of family member – V 61. 08 Due to other extended absence of family member • V 61. 23 Counseling for parent-biologic child problem • V 61. 24 Counseling for parent-adopted child problem • V 61. 25 Counseling for parent/guardian foster child problem • V 61. 42 Substance abuse in family

ICD-9 -CM 2010 Effective October 1, 2009 New V Codes • V 80. 01 Special screening for traumatic brain injury • V 80. 09 Special screening for other neurological condition • V 87. 44 Personal history of inhaled steroid therapy • V 87. 45 Personal history of systemic steroid therapy • V 87. 46 Personal history of immunosuppressive therapy

ICD-9 -CM 2010 Effective October 1, 2009 Invalid Codes • • 768. 7 779. 3 799. 2 V 80. 0 Hypoxic-ischemic encephalopathy Feeding problems in newborn Nervousness Special screening neurological conditions

CPT 2010 Effective January 1, 2010 Concurrent Care and Transfer of Care • Concurrent Care – Similar services to same patient by more than one physician on same day • Transfer of Care – Physician providing management relinquishes responsibility to another accepting physician – Consultation codes only if decision to accept transfer of care cannot be made until initial consultation visit

CPT 2010 Effective January 1, 2010 Consultations • Consultation request documented in patient’s record by either consulting or requesting physician or other appropriate source • Consultation initiated by patient/family – report office visit or hospital E/M codes, not consultation codes

CPT 2010 Effective January 1, 2010 Consultations • F/U visits with consultant – Established patient E/M codes – Additional request for same or new problem from another physician/source, use consultation codes again – Services constituting transfer of care use appropriate new/established E/M codes • Do not report both outpatient and inpatient consultations related to the same inpatient stay

CPT 2010 Effective January 1, 2010 Prolonged Services w/o Direct Pt Contact • 99358 – 99359 – May now be reported on a different date than the primary service Ex: extensive record review before or after visit – Related to any level of E/M service, where direct face to face care will or has occurred – Time cumulative, not continuous – Use only once per date

CPT 2010 Effective January 1, 2010 Vaccines/Toxoids • Term “preservative free” includes products containing either very little or no preservatives • 90669 revised – Pneumococcal vaccine – 7 valent • ~907 XX – Pneumococcal vaccine – 13 valent • 90378 – Respiratory Syncytial Virus – monoclonal antibody, recombinant, 50 mg each

IMPORTANCE OF ACCURATE APPROPRIATE CODING • INCREASED REIMBURSEMENT • DECREASED LIABILITY • IMPROVED INFORMATION FLOW

Increase Reimbursement and Decrease Liability Through Physician Knowledge and Use of Coding Increase revenues by increasing productivity without working harder !

Basic Coding Systems HCPCS: CPT: Complete coding system for all services furnished Healthcare Common Procedural Coding System. Coding for services furnished Current Procedural Terminology ICD-9 -CM: Coding for diagnosis/reason for services International Classification of Diseases, 9 th Revision Clinical Modification RBRVS: Assigns a relative reimbursement for CPT codes Resource Based Relative Value Scale

Evaluation and Management Codes 7 Components The “SCIENCE” of Coding • Key – History – Examination – Medical Decision Making • Contributory – Counseling – Coordination of Care – Nature of Presenting Problem • Explicit – Time – Only to assist physician in selection

History Type HPI ROS PFSH Problem Brief (1 -3) Focused (212) Expanded Brief (1 -3) Problem Focused (213) N/A Brief (1) N/A Detailed Extended (2 -9) Complete (10+) Pertinent (1) Complete (2/3 or 3/3) (214) Extended (4+) Compre Extended hensive (215) (4+)

Examination • Problem Focused (212) – Limited to affected body area or organ system – 1 body area / organ system • Expanded Problem Focused (213) – Affected body area or organ system and other symptomatic or related organ systems – 2 – 4 body areas / organ systems • Detailed (214) – Extended exam of affected body area(s) and other symptomatic or related organ systems - 5 – 7 body areas / organ systems • Comprehensive (215) – Complete single system specialty exam or – Complete multi-system exam – 8 organ systems

Medical Decision Making Straight forward (212) Number of Diagnoses Minimal Amount of Data Risk of Complication Min. or None Minimal Low Complexity Limited (3) Limited Low Moderate Multiple Complexity (4) High Extensive Complexity (5) Moderate Extensive High * 2 of 3 elements met or exceeded

Time • An explicit factor to assist in selecting the most appropriate level of E/M services • When counseling and/or coordination of care more than 50% of the face to face encounter, then time is the key controlling factor. • Utilize prolonged services codes (time based) *Documentation in the medical record is a must

CODING A DAY … • Services Provided: – Face to Face – Non Face to Face – Procedures – Additional Add on Services

6 AM RISE AND SHINE ! • Telephone Call: – Patient calls answering service early: 4 yo with sore throat and fever. • Call returned and parent advised to call office and schedule an ill appointment in the morning • How would you code for this service?

6 AM RISE AND SHINE ! • A. 99212 • C. Not billable service • B. 99441 – Physician telephone • D. 99358 – Prolonged Service call non face/face

6 AM RISE AND SHINE ! • Telephone Call: – To Hospital Pediatric Unit • Check status of patient and modify orders: IV fluids for gastroenteritis and dehydration, Advance diet • How would you code for this telephone work ?

6 AM RISE AND SHINE ! • A. 99221 • C. 99441 - Physician Telephone call (5 -10 minutes) • B. Not billable service • D. 99358 – Prolonged Services non f/f (>30 minutes)

Telephone Services CPT 2008 • 99441 Physician to est patient, parent or guardian 2009 medicare 5 – 10 minutes of medical discussion ($12. 62) No related E/M service within previous 7 days No related E/M service in next 24 hours or next available appointment • 99442 11 – 20 minutes ($24. 89) • 99443 21 – 30 minutes ($38. 33)

7 AM NURSERY TIME • Hospital Nursery – Term healthy newborn female Routine history, examination, medical decision making Institute routine management orders • How would you code for these services?

7 AM NURSERY TIME • A. 99431 • C. 99460 • B. 99221 • D. 99381

Key Concepts - Inpatient E/M Coding • Code for services only the day the patient is seen (face to face) • One E/M code per day ( few exceptions – 25 Modifier) • Time spent is “unit/floor time” • Attending physician must see the patient and fulfill and document criteria supporting code used • Procedures should be coded separately (few exceptions – Newborn /Critical care codes)

Normal Newborn Care 2009 • • • 99431 99432 99433 99435 99238 99239 Initial Hospital → Other Setting → Subsequent Hospital→ Same day Admit/Discharge → Discharge ≤ 30 minutes Discharge >30 minutes • 99436 Attendance at delivery → • 99440 Delivery Resuscitation → • • • 99460 99461 99462 99463 Unchanged • 99464 • 99465

7 AM NURSERY TIME • Hospital Nursery – Term healthy newborn male • Discharge: Routine history, examination • Extensive time spent dealing with maternal anxiety and feeding concerns • Circumcision • How would you code for these services?

7 AM NURSERY TIME • A. 99238 54150 (circumcision) • C. 99460 54150 • B. 99231 54150 • D. 99239 54150

CPT Changes 2007 Circumcision Codes Revised • 54150 Circumcision, clamp or other device, with regional dorsal penile or ring block – Use -52 modifier if w/o block – Do not separately report 64450 for nerve block • 0 day global code • -25 modifier on associated E/M code (99239 -25)

25 Modifier • To support a separate and distinct evaluation and management service the day of the circumcision – Code the appropriate E/M visit in addition to the circumcision procedure - Add modifier – 25 to the E/M code

7: 30 AM NURSERY TIME • Hospital Nursery 2 Day old infant with hyperbilirubinemia • Phototherapy initiated for bilirubin of 17 following AAP guidelines Expanded problem focused history and examination, mod complexity med decision making • How would you code for this days services?

7: 30 AM NURSERY TIME • A. 99433 • C. 99462 • B. 99232 • D. 99231

Subsequent Hospital Care Code 99231 99232 99233 History Problem Focused Detailed Exam Problem Focused Expanded Problem Focused Decision Making Straightfd/ Low Complexity Mod Complexity High Complexity Time/ Floor 15 25 35 Key # 2 of 3 Detailed

8 AM NIGHT TIME CHALLENGE • Pediatric Unit 4 yo with gastroenteritis/dehydration, admitted from ED evening during the night. Calls made related to management • Admission H&P, Orders, Discussion with parents; Comprehensive Hx and Exam, Mod complexity MDM (Extensive discussion with parents > 70 minutes) How would you code for these time intensive services?

8 AM NIGHT TIME CHALLENGE • A. 99222 • C. 99214 • B. 99232 • D. 99253

Initial Hospital Care/ New or Est. Code 99221 99222 History Detailed or Comprehensiv e e Decision Making Straightfd or Low Complexity Mod Complexity High Complexity Time/ Floor 30 50 70 Key # 3 of 3 Exam 99223 Comprehensiv e e

9 AM THE FRONT LINE • Arrive at office Scheduled to start with a preventive medicine visit at 9 am; However, the telephone staff had an infant with acute respiratory distress “come right in”. Your nurse tells you this child is “sick” and you need to see him now, disrupting your schedule.

9 AM THE FRONT LINE • You see this patient, completing a detailed history, detailed physical examination, and moderate complexity decision making. • The infant has a pulse ox of 95% in RA prior to treatment • An albuterol aerosol is given with dramatic improvement; O 2 sat improves to 98% • The infant is sent home with instructions on use of home aerosols • F/U planned in two days How would you Code for the E/M services for this patient ?

9 AM THE FRONT LINE • A. 99213 • C. 99215 • B. 99214 • D. 99215 + prolonged services

9 AM THE FRONT LINE • A. 99058 – Emergency office service • B. 94760 – Pulse Oximetry • C. 94640 – Aerosol 94664 – Aerosol/MDI Teaching • All of the above

Minor Office Procedures Non Facility CPT Aerosol Rx only (X -76) 94640 Allergy injection (#1) 95115 #2 or more 95117 Cerumen Removal 69210 Lumbar Puncture 62270 Urine Catherization 51701 Venipuncture <3 yrs 36406 Venipuncture >3 yrs 36410 Venipuncture /Routine 36415 Finger/Heelstick 36416 RVU/ 2009 Medicare 0. 37/ $13. 34 0. 29/ $10. 46 0. 35/ $12. 62 1. 25/ $45. 08 4. 14/$151. 59 1. 71/ $58. 93 0. 45/ $15. 63 0. 50/ $17. 30 0. 26/ $ 9. 17 0. 15/ $5. 25

Examples of medical services RVU/2009 Medicare • • • 96360 - IV fluids, first hour 96372 - Injection SQ/IM 93000 – EKG/ w interpretation 93010 - EKG/ interpretation only 94010 - spirometry w/o bronchodilator 94060 - spirometry pre/post-bronchodilator 86580 -PPD 94664 – teaching nebulizer, MDI (-59) 92567 - tympanometry 94760 - pulse oximetry 1. 57/ $56. 62. 58/ $20. 17. 25/ $8. 92. 91/ $31. 20 1. 6/$55. 08. 20 / $6. 91. 41/ $14. 15. 49 / $17. 57. 08/ $2. 89

Special Services and Reports “Modifier-Like” Codes • 99000 – Handling and/or conveyance of a specimen from office to laboratory • 99050 - Services provided in office other than regularly scheduled hours normally closed • 99051 - Services provided in office during regularly scheduled evening, weekend, holiday hours • 99053 - Services provided 10 PM to 8 AM at 24 hour facility • 99058 - Office services on an emergency basis Codes billed in addition to basic service

9: 30 AM WELL BABY TIME • A two month old infant is scheduled for the initial routine office visit. An age appropriate Hx and PE are completed. There are no significant problems. Age specific feeding, infant behavior and anticipatory guidance is provided. Immunizations are given following the AAP/ACIP periodicity schedule. • How would you code for the E/M work ?

9: 30 AM WELL BABY TIME • A. 99213 • C. 99381 • B. 99214 • D. 99391

Preventive Medicine Services • E/M services performed in the absence of a significant problem/abnormality • Extent and focus depends on the patient’s age • Include counseling/anticipatory guidance/risk factor reduction • Do not include office procedures, ancillary services, and immunizations

Preventive Medicine Services New Patient Initial E/M of a new patient including an age and gender appropriate history, examination identification of risk factors, ordering of appropriate tests, and counseling RVU/ 2009 Medicare 99381 Age < 1 year 2. 51/ $ 90. 53 99382 Ages 1 – 4 years 2. 73/ $ 98. 46 99383 Ages 5 – 11 years 2. 71 /$ 97. 74 99384 Ages 12 – 17 years 2. 95/ $106. 40 99385 Ages 18 – 39 years 2. 95/ $106. 40

Preventive Medicine Services Established Patient Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk factors, ordering of studies, and counseling RVU/ 2009 Medicare 99391 Age < 1 2. 09/ $75. 38 99392 Ages 1 – 4 years 2. 33/ $84. 04 99393 Ages 5 – 11 years 2. 32 /$83. 67 99394 Ages 12 – 17 years 2. 55/ $91. 97 99395 Ages 18 – 39 years 2. 56/ $92. 33

9: 30 WELL BABY TIME • A. 90471 90472 X 2 90474 Immunization products • C. 90465 90466 X 2 90468 Immunization products • B. 90471 90472 X 2 90473 Immunization products • D. 90465 90466 X 2 90467 Immunization products

Immunizations • Bill and Document ALL: – E/M Visit • Office Visit, Preventive Medicine – Immunization Administration • 90471 – 90474 • 90465 - 90468 (2005 Peds specific) – Vaccine/Toxoid • 90476 – 90749 • Link to ICD Diagnoses – V 20. 2 Well Child – CSHCN Diagnosis – + Specific Vaccine V Codes

EXISTING CPT CODES 2004 Vaccine Administration • 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) • 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) • 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) • 90474 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

2005 “NEW” CPT CODES Vaccine Administration • 90465 Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day • 90466 each additional injection (single or combination vaccine/toxoid), per day • 90467 Immunization administration under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day • 90468 each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)

Vaccine Administration RVUs for 2009 • Values - Existing codes RVU 2009 medicare – 90471 – 0. 58/ $20. 92 – 90473 – 0. 38/ $13. 71 • Values - New codes – 90465 – 0. 58/ $20. 92 - 90467 -0. 38/ $13. 71 RVU 2009 medicare 90472 – 0. 29/ $10. 46 90474 – 0. 25/ $ 9. 02 90466 – 0. 29/ $10. 46 90468 – 0. 28/ $10. 10

? -25 Modifier

10: 00 AM ? WELL BABY TIME • A 6 month infant boy presents for a scheduled preventive visit. His mother is worried about the cold and fever he has had for several days. An age and gender appropriate Hx and PE are completed, in addition to an extended Hx addressing the ongoing illness. A Dx of otitis media is made and the infant is treated with po amoxicillin. His mother is not comfortable with proceeding with immunizations. It is agreed that she will return in several weeks for a nurse only visit to obtain these important vaccines. • How would you code for this office visit ?

10: 00 AM ? WELL BABY TIME • A. 99391 • C. 99391 99213 -25 • B. 99214 • D. 99391 99212 -25

Preventive Medicine vs E/M Office Visit ? What do you do if a significant illness or problem is found at a preventive medicine visit?

25 Modifier • If a significant problem/abnormality is found at a preventive medicine visit: – Code the appropriate E/M visit in addition to 99381 – 99395 - Add modifier – 25 to the E/M code - If not significant code only 99381 – 99395 - Option: Have patient return for a separate E/M visit for problem/abnormality found

25 Issues • Coverage NCCI Edits • Copays • Separate Documentation • Supporting Diagnosis

10: 30 AM COMPLETE PHYSICAL TIME • A 5 yo est patient presents for her school PE. She has been a healthy girl with no significant parent concerns. An age and gender appropriate Hx and PE are completed. Following Bright Futures guidelines, hearing and vision screening are completed. A Hgb is also obtained, and immunizations are given. • How would you code for the E/M service ?

10: 30 AM COMPLETE PHYSICAL TIME • A. 99393 • C. 99214 • B. 99383 • D. 99215

10: 30 AM COMPLETE PHYSICAL TIME • A 5 yo girl presents for her school PE. She has been a healthy girl with no significant parent concerns. An age and gender appropriate Hx and PE are completed. Following Bright Futures guidelines, hearing and vision screening are completed. A Hgb is also obtained, and immunizations are given. • Can you code for the screening work provided ? Do you need a -25 modifier ? How is it attached ?

10: 30 AM COMPLETE PHYSICAL TIME • A. Hearing and Vision • C. Hgb testing included in recommended preventive medicine visit 36416 (fingerstick) 85018 (Hgb) • B. 92551 (hearing) 99173 (vision) • D. -25 modifier required 99393 -25

Screening services • • RVU/ 2009 Medicare 92583 - hearing screen, select picture. 91/ $31. 30 92551 - hearing screen, pure tone. 29/ $10. 46 92552 –hearing screen, pure tone threshold. 59/ $21. 28 99173 - visual acuity screening. 07/ $2. 52 – may be reported w/ preventive care codes, not if part of an E/M service of the eye

10: 30 AM COMPLETE PHYSICAL TIME • A 5 yo girl presents for her school PE. She has been a healthy girl with no significant parent concerns. An age and gender appropriate Hx and PE are completed. Following Bright Futures guidelines, hearing and vision screening are completed. A Hgb is also obtained, and immunizations are given. (DTa. P; IPV; MMR; Varivax) • How would you code for the immunizations provided ?

10: 30 AM COMPLETE PHYSICAL TIME • A. 99393 90465 90466 X 3 • C. 99393 -25 90466 X 3 • B. 99393 90471 90472 X 3 • D. 99393 -25 90471 90472 X 3

Special Office Services 2008 RVU/ $ Medicare • Insurance Forms • Charge for Forms! 99080 000/ 000

11 AM MAKE ME BETTER TIME • A 12 yo teenager est patient presents with a severe sore throat for 2 days, associated with a fever and swollen glands. An expanded problem focused Hx and PE are done. A strep FA is obtained and treatment with acetaminophen/ibuprofen reviewed. • How would you code for this patient ?

11 AM MAKE ME BETTER TIME • A. 99212 87880 (strep FA) • C. 99214 87880 (strep FA) • B. 99213 87880 (strep FA) • D. 99394 87880 (strep FA)

Key Concepts – Outpatient E/M Coding • Time spent is “face to face” • One E/M code per day – Few exceptions: • -25 modifier • Prolonged services codes • Attending physician must see the patient and fulfill / document criteria supporting code used • Procedures and other services should be coded separately – May require modifiers (-25 on the E/M code)

Office Visits – New Patient Codes 99201 99202 History Problem Focused Exam Problem Focused Decision Making Time FF Key # 99203 99204 99205 Expanded Detailed Problem Focused Compre hensive Straight forward Expanded Detailed Problem Focused Straight Low forward complex Moderate complex High complex 10 3 of 3 20 3 of 3 45 3 of 3 60 3 of 3 30 3 of 3

Office Visits – Established Patient Codes 99211 99212 99213 99214 99215 History Not Required Problem Focused Expanded Detailed Problem Focused Compre hensive Exam Not Required Problem Focused Compre hensive Decision Making Not Required Straight forward Expanded Detailed Problem Focused Low Mod Complex Time FF 5 10 15 25 40 Key # 2 of 3 2 of 3 High Complex

The ART of Coding • The “FEEL” – Established Patient – 99211 - Nurse Visit – 99212 - Easy, Brief Problems – 99213 - Average, Usual Problems – 99214 - “ OH NO !” – 99215 - “ Just Ran a Marathon”

11: 15 I’M STILL SICK TIME ! • Our patient returns 5 days later. She is miserable, cannot swallow, and looks dry. She is congested and has been sleeping all the time. An detailed Hx and PE is completed. Lab work including a Mono spot, chem-8, and urinalysis are ordered. Extensive discussion re the DDx, Rx and F/U is completed. The patient is treated with a short course of steroids when the Mono spot is positive. • How would you code for these services ?

11: 15 I’M STILL SICK TIME ! • A. 99213 36415 (venipuncture) 99000 (specimen transfer) • C. 99214 36415 (venipuncture) 99000 (specimen transfer) • B. 99233 36415 (venipuncture) 99000 (specimen transfer) • D. 99215 36415 (venipuncture) 99000 (specimen transfer)

Codes 99211 99212 99213 99214 99215 History Not Required Problem Focused Expanded Detailed Problem Focused Compre hensive HPI 1 -3 ROS N/A PFSH N/A HPI 1 -3 HPI 4+ ROS 1 ROS 2 -9 ROS 10+ PFSH N/A PFSH 1/3 PFSH 2/3 Problem Focused Expanded Detailed Problem Focused 1 Area 2 -4 Areas 5 -7 Areas >8 Areas Required Elements Exam Not Required Elements Compre hensive Decision Making Not Required Straight forward Low Complex Mod Complex High Complex Time FF 5 10 15 25 40 Key # 2 of 3 2 of 3

11: 30 QUICK SICKIE TIME • A 13 yo boy comes in announcing he has poison ivy. A brief Hx and PE support his diagnosis. It is in several small patches on his extremities. You treat with a topical steroid prescription. • How would you code for this quickie ?

11: 30 AM QUICKIE SICKIE TIME • A. 99213 • C. 99211 • B 99214 • D. 99212

11: 45 LUNCH TIME/ DISASTER TIME • A 15 yo patient of your partner is scheduled with a cc of “anxiety attacks”. She is inappropriately scheduled in a 10 minute ill appointment time. You complete a comprehensive Hx, extended PE, and provide extensive counseling for this adolescent who is depressed and suicidal. Total face to face time for this encounter is 50 minutes, with 30 minutes spent counseling and coordinating care for this crisis. • How would you code for this total loss of your lunch time ?

11: 45 am LUNCH TIME/DISASTER TIME • A. 99214 • C. 99354 (prolonged services) • B. 99215 • D. 99204

Use Time !

LUNCH TIME + • Your lunch time has been lost, but you are still on schedule. You have time to make one 10 minute phone call to a patient who is having issues with toilet training her 3 yo son. This is not related to a previous visit and does not result in a scheduled E/M visit. • How would you code for this time consuming work? Is this a billable service?

LUNCH TIME + • A. 99441 • C. Not a billable service! • B. 99358 (1 st hour non f/f) • D. 99211

Non Face-to-Face Non-Physician Services CPT 2008 • Telephone – by qualified non-physician health care professional No related E/M service previous 7 days No related other service in next 24 hours or next available appointment 2009 medicare 98966 5 – 10 minutes medical discussion ($12. 26) 98967 11 – 20 minutes ($24. 89) 98968 21 – 30 minutes ($37. 15)

Online Medical Evaluation CPT 2008 • 99444 Online E/M service provided by a physician to an est patient, parent, guardian or health care provider Not originating from related E/M service in previous 7 days In response to patient’s online inquiry Using internet or similar communications network Requires “timely response” Permanent storage of encounter ($0. 00)

Non Face-to-Face Non-physician Services CPT 2008 • Online Medical Evaluation • 98969 Online assessment and management, by non-physician health care professional No related assessment and management service in previous 7 days Using internet or similar electronic communication network In response to patient’s on line inquiry ($0. 00) Timely response with permanent storage of encounter

TAKE A BREAK !

1 PM DAILY GRIND TIME • You settle into the afternoon pace with an 18 month old female scheduled for a preventive medicine visit. This is completed using a template for an 18 month visit. ASQ developmental and MCHAT autism screenings are completed following Bright Futures guidelines. The patient will receive Hep A #2 and HIB #4 immunizations. • How would you code for the E/M and screening services?

1 PM DAILY GRIND TIME • A. 99392 Screening included • C. 99382 96110 X 2 • B. 99392 96110 X 2 (standardized dev screening) • D. 99392 -25 96110 -59

Developmental Testing Codes Central Nervous System Assessments/Tests • 96110 Developmental Testing, limited • Performed by office nurse or other trained nonphysician personnel • Parent/guardian report of behavior • RVU 0. 36 $12. 98 2009 medicare • Modifier – 25 may be attached to associated E/M visit • Modifier -59 to multiple additional tests • Interpretation and report Documentation in progress report of E/M visit

96110 Examples • • Ages and Stages Questionnaire (ASQ) Brigance Early Preschool Developmental Profile II Early Language Milestone Scales PEDS PDQ Vanderbilt MCHAT • NOT direct physician observation or general developmental assessment with checklist of milestones appropriate for age

1 PM DAILY GRIND TIME • You settle into the afternoon pace with an 18 month old female schedule for a preventive medicine visit. This is completed using a template for an 18 month visit. ASQ developmental and MCHAT autism screenings are completed following Bright Futures guidelines. The patient will receive Hep A #2 immunization. • How would you code for the immunization?

1 PM DAILY GRIND TIME • A. 99392 Immunizations included • C. 99382 99465 • B. 99392 99471 • D. 99392 -25 99465

Preventive Medicine Ancillary Services Screening RVU/ 2009 Medicare Hearing testing - Select picture 92583. 91/ $31. 30 Hearing testing – Puretone 92551. 29/ $10. 46 Hearing testing – Puretone(threshold) 92552. 59/ $21. 28 Vision screening 99173. 07/ $2. 52 Developmental Screening 96110. 36/ $12. 98 Lab Hemoglobin 85018. 10/ $3. 45 Urine (dip only) 81002. 08/ $2. 78 Routine Venipuncture 36415. 26/ $9. 17 Finger/Heel Stick 36416. 15/ $5. 25 Immunizations Immunization administration 90471/90465. 58/ $20. 92 90472/90466. 29/ $10. 46 Vaccine/Toxoid product 90476 -90479 Other Injection/other 96372. 58/ $20. 17

1: 15 PM ? CONSULTATION TIME ? • Your 3 yo established patient with significant caries and associated dental abscess problems is scheduled for general sedation and teeth extraction at the ambulatory surgical center. She is scheduled for a preop visit. The patient has an Expanded problem focused history and examination. She has no significant problems. The preop form is completed. • How would you code for this visit for your established patient?

1: 15 PM DENTAL PREOP • A. 99214 • C. 99242 • B. 99241 • D. 99252

Provide Consultations ! 99241 -99245 • Payment is 25 -42% higher than corresponding new patient office visit codes, and… • Documentation requirements for History, Exam, and MDM are the same! • Consult codes are problem-based and can be used for new or established patients

Consultations – 5 R’s - 2008 REASON: Medically necessary REQUEST: By another physician or other appropriate source RENDER: May initiate diagnostic and/or therapeutic services REPORT: By written report back to the requesting source RETURN: Patient back to requesting physician/source

Office Consultation/ New or Est Code 99241 99242 History Problem Focused Exam 99243 99244 99245 Expanded Detailed Problem Focused Compre hensive Decision Making Expanded Detailed Problem Focused Straightfd Low Complex Mod Complex High Complex Time FF 15 30 40 60 80 Key # 3 of 3 3 of 3

Inpatient Consult / New or Est. Code 99251 99252 History Problem Focused Exam Problem Focused Decision Making Straightfd 99254 99255 Expanded Detailed Problem Focused Compre hensive Straightfd Low Complex Mod Complex High Complex Time/unit 20 40 55 80 110 Key # 3 of 3 3 of 3 99253

Code for extensive medical services • $ OV < Prev Med < Consultation

1: 30 PM DAILY GRIND (PLUS) TIME • A 12 yo boy is scheduled for a sports physical. A complete preventive medicine visit is completed. He has a history of mild intermitent asthma, and is currently managed with a steroid inhaler and prn albuterol MDI. Spirometry is completed supporting good control. He receives scheduled immunizations and is instructed in the use of his MDI. • How would you code for this “physical” ? • How would you code for all the associated services?

1: 30 PM DAILY GRIND (PLUS) TIME • A. 99394 99213 94010 (spirometry) • C. 99394 • B. 99394 -25 99213 94010 (spirometry) • D. 99394 99213 -25 94010 (spirometry)

Examples of medical services RVU/2009 Medicare • • • 96360 - IV fluids, first hour 1. 57/ $56. 62 96372 - Injection SQ/IM. 58/ $20. 17 93000 – EKG/ w interpretation. 58/ $20. 17 93010 - EKG/ interpretation only. 25/ $8. 92 94010 - spirometry w/o bronchodilator. 91/ $31. 20 94060 - spirometry pre/post-bronchodilator 1. 6/$55. 08 86580 -PPD. 20 / $6. 91 94664 – teaching nebulizer, MDI (-59). 41/ $14. 15 92567 - tympanometry. 49 / $17. 57 94760 - pulse oximetry. 08/ $2. 89

2 PM CHALLENGE OF THE DAY TIME • A 1 mos infant female with Down’s syndrome has just been discharged from the NICU. She has a complex VSD and congestive heart failure. She has a feeding tube and is on a CA monitor. Records are reviewed prior to the visit, and calls made to the home nursing service. • How would you code for the work provided for this complex CSHCN patient?

2 PM THE CHALLENGE ! • A. 99215 • C. 99205 99358 (prolonged services non f/f) • B. 99205 • D. 99205 -25 99358

Prolonged Services (99354 -99359) • Code series defining prolonged services by: – Site of service – Direct or without Direct patient contact – Time • Reported in addition to other physician service, including E/M services at any level • Total time for a given date, even if the time is not continuous • Time must be of 30 minutes or more

Prolonged Services Direct Patient Care Face to Face Before or after Face to Face Outpatient Inpatient 99354 first hour > 30 min 99355 each add 30 min > 75 min 99358 first hour > 30 min 99359 each add 30 min > 75 min 99356 first hour > 30 min 99357 each add 30 min > 75 min 99358 first hour > 30 min 99359 each add 30 min > 75 min

2: 30 PM NON PHYSICIAN WORK TIME • A parent comes in for an ADHD medication visit. It has been one month since her son’s scheduled physician visit. He is doing well on his current dose of stimulant medication, sleeping well, and eating well. Some minor home behavioral issues are discussed. The prescription written by the physician is given to the parent, and a visit scheduled in 1 month for the next ADHD f/u appt. • How would you code for this non-physician visit?

2: 30 PM NON PHYSICIAN WORK TIME • A. 99212 • C. 99211 • B. Not billable service • D. Not subject to copay

2: 45 PM NON PHYSICIAN WORK TIME • A parent comes in for a catchup immunization for her 6 month infant who had a febrile URI at the previous preventive medicine visit. He has some persisting congestion. The nurse does an interval Hx, vital signs, and listens to the infants chest with a stethescope. A decision is made to proceed with immunizations, and a visit scheduled in 6 weeks for the next scheduled preventive medicine visit. This E/M visit is carefully documented. • How would you code for this non-physician visit?

2: 45 PM NON PHYSICIAN WORK TIME • A. No billable service • C. 99211 -25 99466 99478 + immunization products • B. 99211 99465 99466 99478 + immunization products • D. 99211 -25 99471 99472 99478 + immunization products

99211 • Typical Presenting Problems Nurse Visit (Provides an E/M Service) – BP Check – Throat Culture – Neonate Weight Check – ADHD Medication Refill – PPD Check – Dressing changes – Simple suture removal – Immunizations – in addition to administration code • Document ! • 99211 Typically Triggers a Copay

3 PM PROCEDURE TIME • A mother brings in her 3 yo girl with a cc of “bad breath”. She has “tried everything” to get rid of it. After an expanded Hx and PE, she is taken to the treatment room where a makeup sponge is removed using bayonette forceps. • How would you code for this procedure?

3 PM PROCEDURE TIME • C. 99213 • A. 30300 (removal of nasal foreign body) • B. 99212 30300 • D. 99213 -25 30300

PROVIDE MORE PROCEDURES ! CODE FOR PROCEDURES !

Code for Those Procedures! Provide more services with procedures (nonfacility): RVU/$2009 Medicare Burn treatment/first degree Burn treatment/debridement Chemocautery/granuloma Chemocautery/epistaxis Circumcision/newborn 16000 (00) 16020 (00) 17250 (00) 30901 (00) 54150 (10) Facility 1. 72/$60. 73 2. 02/$70. 52 1. 84/$66. 36 2. 64/$99. 22 6. 63/$239. 12 2. 81/$101. 35

Code for Those Procedures! Provide more services with procedures (nonfacility): RVU/2009 Medicare Foreign body removal/ear Foreign body removal/nose FB removal/subcutaneous Incision&Drainage/Simple Wart removal (1 -14) Wart removal (15 or >) Wound repair/dermabond 69200 30300 10120 10060 17111 12011 (00) (10) (10) 3. 02/$108. 92 5. 47/$186. 55 3. 33/$120. 10 2. 72/ $98. 10 2. 70/ $97. 38 3. 20/ $115. 41 3. 87/$135. 84

Orthopedic Procedures RVU/Medicare Subluxation of radial head Closed Rx radial fx Closed Rx distal phalanx fx Closed Rx proximal or middle phalanx fx Closed Rx toe fx Closed Rx great toe fx Closed Rx clavicle fx Splint forearm 2009 24640 25500 26750 26720 2. 89/ $104. 23 6. 23/ $218. 75 4. 25/ $149. 09 4. 55/ $159. 24 28510 28490 23500 29125 2. 87/ $100. 44 3. 30/ $114. 82 5. 12/ $184. 66 1. 63/ $56. 82

Use HCPCS Codes for Supplies • If not included as standard practice expense for the procedure (Practice expense component of RBRVS) • CPT 99070 General Nonspecific code for supplies • HCPCS codes are preferable Alphanumeric

HCPCS Codes Used to report supplies • J 1100 - Dexamethasone injection, 1 mg • J 0170 - Epinephrine • J 0696 - Ceftriaxone, per 250 mg • J 7613 - Albuterol for inhalation, 1 unit dose

3: 30 PM FUSSY BABY TIME • A 2 mos infant has been fussy since birth. He is difficult to console and has been very spitting, with vomiting once/ day. There have been no other symptoms of illness. A detailed history and detailed examination are completed. 15 minutes of face to face time are recorded for the visit. • How would you code for this fussy baby and fussy parent?

3: 30 FUSSY BABY TIME • A. 99212 • C. 99214 • B. 99213 • D. 99215

4 PM TEEN TROUBLE TIME • A 13 yo boy has been failing in school and was suspended today for threatening another student. Your assessment includes a plan to evaluate for ADHD/ learning disabilities, as well as, obtain counseling for his significant home and school adjustment problems. Total face to face time for the visit is 45 minutes, with 30 minutes spent counseling and coordinating care related to the issues, Dx, and Rx options. • How would you code for this troubled teen visit?

4 PM TROUBLED TEEN TIME • A. 99214 • C. 99213 • B. 99215 • D. 99213 99354 (prolonged services f/f)

Documentation/ ICD 9 CM • ICD coding should support higher levels of coding (medical necessity) • 99213 to 99215 • Code multiple diagnoses • Code comorbidities • Document chronic condition when an acute problem is presented – Asthma – Diabetes mellitus – Prematurity and related problems

4: 30 PM THE STANDARD ILL VISIT • A new patient 4 yo girl presents with several days of burning pain with urination. An expanded problem focused history and expanded problem focused examination are completed. A urinalysis with microscopic analysis is done. The diagnosis is vulvitis and sitz baths are recommended. • What would you code for this bread and butter pediatric visit?

4: 30 PM THE STANDARD ILL VISIT • A. 99213 81000 (u/a with micro) • C. 99202 81000 (u/a with micro) • B. 99203 81000 (u/a with micro) • D. 99204 81000 (u/a with micro)

4: 45 PM ANOTHER ONE! • A 3 yo female presents with twelve hours of fussiness and vomiting. She does not have fever and is urinating well. An expanded problem focused history and examination are completed. Slowly advancing clear fluids is reviewed, as well as, when to call if her condition worsens. • How would you code for this everyday patient?

4: 45 PM ANOTHER ONE! • A. 99212 • C. 99213 • B. 99214 • D. 99215

4: 45 PM ANOTHER SICKER ONE! • A 5 yo female presents with one day of vomiting. She has a temp of 101, diarrhea, and lethargy. She is urinating less and not tolerating “anything”. A detailed history and examination are completed. A negative urinalysis is obtained with a specific gravity of 1. 020. Management is reviewed: slowly advancing clear fluids, treatment of fever, and when to call. • How would you code for this everyday patient?

4: 45 PM ANOTHER SICKER ONE! • A. 99212 81002 (dip urinalysis) • C. 99213 81002 • B. 99214 81002 • D. 99215 81002

5: 00 PM EAR TIME • A 2 yo est patient presents with fussiness, congestion, and pulling at her ears. She is afebrile. An expanded problem focused Hx and PE are completed. Cerumen is removed from both ears to visualize the tympanic membranes. A diagnosis of otitis media is made and the patient treated with po antibiotics. • How would you code for this frequently encountered problem?

5: 00 PM EAR TIME • A. 99212 • B. 99213 69210 (cerumen removal) • C. 99214 (includes cerumen removal) • D. 99213 -25 69210 (cerumen removal)

5: 15 PM SQUEEZE ‘EM IN TIME • A 6 yo boy fell from a swing set and has refused to move his left arm since. On physical examination, he has localized swelling and pain of the mid L clavicle. An Xray is obtained. A sling is applied analgesics recommended. • How would you code for this orthopedic procedure?

5: 15 PM SQUEEZE ‘EM IN TIME • A. 99213 73000 Xray clavicle A 4565 Sling • C. 23500 (Rx fx clavicle) 73000 Xray clavicle A 4565 Sling • B. 99214 73000 Xray clavicle A 4565 Sling • D. 99212 -25 23500 73000 Xray clavicle A 4565 Sling

Fracture Care Which is best ? • Fracture Care Global (90 day) – All visits in global period included – Strapping, splinting, casting included – X-ray, Supplies separately billed – Unrelated E/M service separately billed (-25) – OR Decision for procedure separately billed (-57) VS. • E/M coding Plus – All visits separately billed – Strapping, splinting, casting billed separately – X-ray, Supplies separately billed

6 PM STAY LATE TIME • A parent calls at 5 pm with a 4 yo crying with a severe earache. The office is kept open and the patient arrives at 6 pm. The patient is febrile and irritable. A detailed history and examination are completed. A diagnosis of otitis media is made and the patient treated with amoxicillin. • How would you code for this stay late patient?

6 PM STAY LATE TIME • A. 99213 • C. 99214 -25 99050 • B. 99214 99050 • D. 99213 99051

Special Services and Reports “Modifier-Like” Codes • 99050 - Services provided in office other than regularly scheduled hours normally closed • 99051 - Services provided in office during regularly scheduled evening, weekend, holiday hours • 99053 - Services provided 10 PM to 8 AM at 24 hour facility Codes billed in addition to basic service

DOCUMENT !

AAP Your CODING CONNECTION Coding & Reimbursement Resources • National AAP Coding Hotline: aapcodinghotline@aap. org or 800/433 -9016 ext 4022; free service to members and their office staff • Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9 -CM Flipchart, RBRVS Brochure, AAP News Coding Corner

A Hundred Years From Now It will not matter what my bank account was, the sort of house I lived in, or the kind of car I drove… But the world will be different Because I was important in the life of a CHILD