AHLA Childhood Asthma with Acute Exacerbation ... Original “final” rule was published. ... pregnancy, third trimester

AHLA

Institute on Medicare and Medicaid Payment Issues ● March 26-28, 2014

HH. Introduction to Medical Coding for Payment Lawyers Robert A. Pelaia Senior University Counsel University of Florida–Jacksonville Jacksonville, FL

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American Health Lawyers AssociationInstitute on Medicare and Medicaid Payment Issues

March 26-28, 2014Introduction to Medical Coding for Payment Lawyers

Robert A. Pelaia

Senior University Counsel for Health Affairs - Jacksonville

904-244-3146

[email protected]

Introduction to Medical Coding For Payment Lawyers

Two different coding “systems” currently are used for billing purposes:

• ICD-9-CM (International Classification of Diseases, 9th

Revision, Clinical Modification)

• CPT (Current Procedural Terminology, Fourth Edition)

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ICD-9-CM

International Classification of Diseases, 9th

Revision, Clinical Modification

Originally developed by the World Health Organization in 1948

Diagnosis Codes

ICD-9 - Volume 2

Alphabetic Index to Diseases

• Volume 2 is presented first in the book and provides an alphabetic index to Volume 1 (the Tabular / Numeric List of Diseases).

• This logical placement of the Alphabetic Index allows you to easily locate terms for later verification in Volume 1 (the Tabular / Numeric List of Diseases).

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ICD-9 – Volume 1

Tabular /Numeric List of Diseases

• In back of book, behind Volume 2.

• Volume 1 lists the ICD-9 codes in numeric order and includes seventeen different chapters.

Anatomy of an ICD-9 Code

Three numbers – decimal point – two numbers

• All codes have a minimum of three digits. The three digit code is referred to as the “Category Code”.

• Example of Category Code:

• Infectious and Parasitic Diseases (001 - 139)

• 056 Rubella

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Most of the Volume 1 Category Codes have either one or two levels of subcategories.

The first subcategory is indicated by the addition of a decimal point and a fourth digit after the category code.

• Example of Category Code with first subcategory:

• 056 Rubella

• 056.7 With other specified complications


The second subcategory level is indicated by the addition of a fifth digit. • Example of Category Code with first and second

subcategories:• 056 Rubella

• 056.7 With other specified complications• 056.71 Arthritis due to rubella• 056.79 Other

• 056.8 With unspecified complications• 056.9 Rubella without mention of complication

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Assigning ICD-9 Codes

Step 1

• Review the medical record documentation in order to properly identify the terms that best describe the patient’s diagnosis.


Step 2

• Look up the terms that best describe the patient’s diagnosis in Volume 2 (the alphabetic index) and identify the ICD-9 code that best matches the diagnosis.

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Step 3

• Look up the selected code in Volume 1 (the tabular/numerical list) to make the code selection. Careful attention should be paid to “includes” and “excludes” notes and other instructions in Volume 1.

• Code to the highest level of specificity.

Mini ICD-9 Quiz

• Chronic Obstructive Bronchitis

• ____________

• Childhood Asthma with Acute Exacerbation

• ____________

• Dermatitis due to Cat Hair• _______________

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ICD-10 Implementation

ICD-9 was implemented in 1979 and is outdated.

No longer meets the advances in medicine and technology.

Running out of code expansion capability.

ICD-10 is the tenth revision of the International Classification of Diseases.


Why Make the Changes?

• Modernize Terminology

• Increased information for public health

• ICD-10 code changes impact virtually every system and business process in plan and provider organizations with significant impacts on billing and reimbursement.

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01/16/09 - Original “final” rule was published.Original compliance date for implementation of ICD-10 was October 1, 2013.

09/05/12 - New “final” rule was published.New compliance date for implementation of ICD-10 is October 1, 2014.

ICD-10 StructureICD-9

• 14,315 diagnosis codes

• 3 -5 characters

• First character is numeric or alpha (E or V)

• Characters 2-5 are numeric

• Always at least 3 characters

• Use of decimal after 3 characters

ICD-10

• 69,099 diagnosis codes• 3 -7 characters• Character 1 is alpha (all letters

except U are used)• Character 2 is numeric• Characters 3 -7 are alpha or

numeric• Use of decimal after 3 characters• Use of dummy placeholder “x”• Alpha characters are not case-

sensitive

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ICD-10 Examples

Example:• ICD-9 = 9 Pressure Ulcer Codes

• ICD-10 = 125 Pressure Ulcer Codes

ICD-10 Examples

Laterality

–C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

–C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

–C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

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ICD-10 Examples

Eyes and Ohs! Ones and Zeros! Uh-Oh!

• I Codes – Diseases of Circulatory System

• I63.011 – Cerebral infarction due to thrombosis of right vertebral artery

• O Codes – Pregnancy/Childbirth

• O24.013 - Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester

ICD-10: Similarities to ICD-9

Tabular List is a chronological list of codes divided into chapters based on body system or condition

Tabular List is presented in code number order

Same hierarchical structure

Codes are looked up the same way

• Look up diagnostic terms in Alphabetic Index

• Then verify code number in Tabular List

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Mini ICD-10 Quiz

• Chronic Obstructive Bronchitis

• ____________

• Childhood Asthma with Acute Exacerbation

• ____________

• Dermatitis due to Cat Hair• _______________

CPT

Current Procedural Terminology, Fourth Edition

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CPT

BackgroundCPT was developed and published in 1966 by the American Medical Association. The current version, CPT 2008, is referred to as “CPT-4” because it is the fourth edition of CPT. Annual updates of CPT are not considered new editions.

ApplicationCPT is used for reporting physician (professional) services and technical services provided with the professional services.

CPT

Updating

CPT Codes are updated through a deliberative process of adding, deleting, and revising codes.

CPT codes are updated and revised by the AMA’s CPT Editorial Panel on an annual basis.

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CPT

OrganizationCPT is divided into six sections, followed by six appendices and an alphabetic index. The CPT codes are listed in numeric order within sections and subsections.

• Evaluation and Management (99201 – 99499)

• Anesthesia (00100 – 01999)

• Surgery (10021 – 69990)

• Radiology (70010 – 79999)

• Pathology and Laboratory (80047 – 89356)

• Medicine (90281 – 99607)

CPT Organization

• Section guidelines appear at the beginning of each of the six CPT sections.

• Subsection guidelines appear at the beginning of many of the subsections.

• The guidelines provide definitions and additional information to assist in the proper selection of CPT codes within the corresponding section or subsection.

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CPT

Evaluation and Management Codes

Key Components

• History

• Exam

• Medical Decision Making

New Patient vs. Established Patient

SELECTING LEVEL OF E&M CODES History - Exam – Medical Decision Making

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SELECTING LEVEL OF E&M CODES

Select an E&M Code in 7 Easy Steps!

SELECTING LEVEL OF E&M CODESHISTORY (new patient)

Step 1 - Determine the “name” level of the History component, which will be either…

Problem-focused,Expanded problem-focused,Detailed, orComprehensive.

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SELECTING LEVEL OF E&M CODESHISTORY (new patient)

Step 2 - Convert this “name” level of history into a “number” level.

Problem-focused = Level 1 Expanded problem-focused = Level 2 Detailed = Level 3Comprehensive = Levels 4 & 5

SELECTING LEVEL OF E&M CODESEXAM (new patient)

Step 3 - Determine the “name” level of the Exam component, which will be either…

Problem-focused,Expanded problem-focused,Detailed, or Comprehensive.

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SELECTING LEVEL OF E&M CODESEXAM (new patient)

Step 4 - Convert this “name” level of exam into a “number” level.

Problem-focused = Level 1Expanded problem-focused = Level 2Detailed = Level 3Comprehensive = Levels 4 & 5

SELECTING LEVEL OF E&M CODESMEDICAL DECISION MAKING (new patient)

Step 5 - Determine the “name” level of the Medical Decision Making component, which will be either…

Straightforward,Low complexity,Moderate complexity, orHigh Complexity.

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SELECTING LEVEL OF E&M CODESMEDICAL DECISION MAKING (new patient)

Step 6 - Convert this “name” level of Medical Decision Making into a “number” level.

Straightforward = Levels 1 & 2Low complexity = Level 3Moderate complexity = Level 4High Complexity = Level 5

SELECTING LEVEL OF E&M CODESPutting It All Together

NOTE: The same “name” level of an element may result in a different “number” level depending on the type of service being coded.

For instance, a Detailed history translates to a Level 3 when looking at the NEW Patient Office Visit range of codes (99203).

HOWEVER, a Detailed history translates to a Level 4 when looking at the ESTABLISHED Patient Office Visit range of codes (99214).

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In cases where a “name” level is associated with TWO number levels, credit the higher number level.

For example: in the NEW Patient Office Visit subcategory, a Comprehensive level of history is associated with both the Level 4 and Level 5 codes within that category, so the Comprehensive history would be converted to a (number) Level 5 history in this category.


In cases where a “name” level is associated with TWO number levels, credit the higher number level.

Another example: in the NEW Patient Office Visit subcategory, a Straightforward level of MDM is associated with both the Level 1 and Level 2 codes within that category, so the Straightforward MDM should always be converted to a (number) Level 2 MDM in this category.

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Step 7 - With a “number” level in hand for each of the three key components, determine whether you must now apply the “3/3 rule” or “2/3 rule” to arrive at the final code level for the category in question.

3/3: When using the 3/3 rule, the LOWEST of the three individual component levels IS the final visit level.

2/3: When using the 2/3 rule, the NEXT-TO-LOWEST component level IS the final visit level.


Mini E&M Quiz

• New Patient Visit (3/3 rule)

• Level 3 History (detailed)

• Level 3 Exam (detailed)

• Level 2 MDM (straightforward)

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Mini E&M Quiz

• New Patient Visit (3/3 rule)

• Level 5 History (comprehensive)

• Level 4 Exam (comprehensive)

• Level 3 MDM (low complexity)


Mini E&M Quiz

• Established Patient Visit (2/3 rule)

• Level 4 History (detailed)

• Level 3 Exam (expanded problem focused)

• Level 2 MDM (straightforward)

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Mini E&M Quiz

• Established Patient Visit (2/3 rule)

• Level 2 History (problem-focused)

• Level 2 Exam (problem-focused)

• Level 3 MDM (low complexity)

Assigning CPT Codes

Step 1

Review the medical record documentation in order to properly identify the terms that best describe the service.

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Assigning CPT Codes

Step 2

Look up the terms that best describe the service in the CPT index and identify the CPT code that best matches the service.

Assigning CPT Codes

Step 3

Look up the selected code in the main section of CPT to make the code selection. Careful attention should be paid to use of modifiers.

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Mini CPT Quiz

• Soft Tissue Shoulder Biopsy

• ____________

• Removal of Foreign Body, External Eye; Conjunctival Superficial

• ____________

• Electrolyte Panel - Pathology• ______________

CPT – Modifier Examples

Modifier 25 - Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service.

Modifier 25 is used to describe separate, distinctly identifiable services from other services or procedures rendered during the same visit. Always attach the modifier to the evaluation and management code.

Modifier 57 - Decision for Surgery.

Modifier 57 is used when an evaluation and management (E&M) service resulted in the initial decision to perform surgery. Major surgical procedure is defined by CMS as a procedure having a 90-day global period assigned by CMS. The global period includes the 1-day prior to surgery.

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Model Compliance Plan for Physician Practices

Issued: October 5, 2000

The OIG Compliance Guidance for Individual and Small Group Physician Practices is available on the OIG’s web site at:

http://oig.hhs.gov/fraud/complianceguidance.html

Specific Risk Areas

Coding and Billing

Billing for items or services not rendered or not provided as claimed.

Submitting claims for equipment, medical supplies and services that are not reasonable and necessary.

Double billing resulting in duplicate payment.

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Specific Risk Areas

Coding and Billing

Billing for non-covered services as if covered.

Knowing misuse of provider identification numbers, which results in improper billing.

Billing for unbundled services.

Specific Risk Areas

Coding and Billing

Failure to properly use coding modifiers.

Clustering

Upcoding the level of service provided.

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OIG Work Plan - Fiscal Year 2014

On January 31, 2014, the Office of Inspector General (OIG) published its proposed Work Plan for Fiscal Year 2014

The Work Plan is available on the OIG’s web site at:

http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf


The Plan, which describes new and ongoing audit and enforcement priorities of the OIG, is helpful in indentifying coding risk areas and providing focus for coders’ ongoing efforts relating to their compliance program activities, audits, and policy development.

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Individuals involved in coding activities should carefully review the OIG Work Plan to ensure that they are aware of all of the coding risk areas identified by the OIG.

OIG Work Plan - Fiscal Year 2014 Billing/Coding-Related Items in the 2014 Work Plan

Anesthesia ServicesReview whether Medicare payments for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements.

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Laboratory Tests - Billing Characteristics and Questionable Billing

Review billing characteristics for Part B clinical laboratory tests and identify questionable billing.


Place of Service Errors

Review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments.

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Mental health providers - Medicare enrollment and credentialing

Review and describe Medicare’s mental health provider enrollment and credentialing requirements and assess CMS’s oversight efforts to verify the qualifications of mental health providers.


Ophthalmologists - Questionable Billing

Review Medicare claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during 2012.

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Evaluation and Management Services

Determine the extent to which selected payments for E/M services were inappropriate.


Sleep Disorder Clinics - High Utilization of Sleep Testing Procedures

Examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures.

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Top 10 Takeaways1. ICD-9 Codes are Diagnosis Codes

2. ICD-10 is Effective October 1, 2014

3. Volume 2 / Front / Alphabetic

4. Volume 1 / Back / Numeric

5. CPT Codes are Procedure Codes

Top 10 Takeaways6. E&M Codes Have 3 Key Components

7. History / Exam / MDM

8. New Patient E/M = 3 Key Components

9. Established E/M = 2 Key Components

10. Code to Highest Level of Specificity

Documents

AHLA Childhood Asthma with Acute Exacerbation ... Original “final” rule was published. ... pregnancy, third trimester