Developmental Screening: Billing and Coding Michelle M. Macias, MD D-PIP Training Workshop June 16, 2006 I have no relevant financial relationships with

Developmental Screening:Billing and Coding

Michelle M. Macias, MDMichelle M. Macias, MD

D-PIP Training WorkshopD-PIP Training WorkshopJune 16, 2006June 16, 2006

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

Importance of Accurate Coding

Improved Information ProcessingImproved Information Processing

– Accurate diagnostic coding requires analyzing all Accurate diagnostic coding requires analyzing all

provided information (subjective and objective)provided information (subjective and objective) Decreased LiabilityDecreased Liability

– DocumentationDocumentation Medico-legalMedico-legal

– ComplianceCompliance Increased ReimbursementIncreased Reimbursement

– One minute of extra work can result in an One minute of extra work can result in an increased code levelincreased code level

Diagnostic Codes

International Classification of Diseases-International Classification of Diseases-Tenth Revision, Clinical Modification (ICD-Tenth Revision, Clinical Modification (ICD-10-CM)10-CM)– Arranges diseases and injuries into groups Arranges diseases and injuries into groups

according to established criteriaaccording to established criteria– NumericNumeric– Revised ~ q 10 years by WHO, annual updates Revised ~ q 10 years by WHO, annual updates

by Health Care Financing Administration by Health Care Financing Administration (HCFA)(HCFA)

– U.S. still using ICD-9 codes, gradually U.S. still using ICD-9 codes, gradually implementing ICD-10implementing ICD-10

ICD-9 Codes Code to the highest degree of specificityCode to the highest degree of specificity Code to the highest degree of certainty for the Code to the highest degree of certainty for the

encounter such as symptoms, signs, abnormal encounter such as symptoms, signs, abnormal test resultstest results

Probable, suspected, questionable, or rule out Probable, suspected, questionable, or rule out should not be codedshould not be coded

List the ICD-9/10 code that is identified as the List the ICD-9/10 code that is identified as the main reason for the service first, then list co-main reason for the service first, then list co-existing conditionsexisting conditions

Chronic disease treated on an ongoing basis Chronic disease treated on an ongoing basis may be codedmay be coded

Do not code for conditions previously tx that Do not code for conditions previously tx that no longer existno longer exist

Developmental Coding: Examples

783.42 Delayed milestones783.42 Delayed milestones 728.85 Hypertonia728.85 Hypertonia 315.31 Language disorder, 315.31 Language disorder,

developmentaldevelopmental 315.9 Learning disorder, NOS315.9 Learning disorder, NOS 348.3 Static encephalopathy348.3 Static encephalopathy

Current Procedural Terminology (CPT)

Published by the AMAPublished by the AMA

Listing of the codes and Listing of the codes and

descriptions for procedures, descriptions for procedures,

services and suppliesservices and supplies

Used to bill insurance carriersUsed to bill insurance carriers

CPT Coding5 Basic Principles of Use

Practitioner should select diagnosis and Practitioner should select diagnosis and procedure codesprocedure codes

Document patient’s services to support Document patient’s services to support codes (compliance)codes (compliance)

Use separate codes for different encountersUse separate codes for different encounters Learn to use modifiers, testing and add-on Learn to use modifiers, testing and add-on

codescodes Design a superbill/computerized routing Design a superbill/computerized routing

sheetsheet

“RVU Review”

Resource Based Relative Value Scale Resource Based Relative Value Scale (RBRVS) (RBRVS)

Relative Value Units (RVUs): “The Coin of Relative Value Units (RVUs): “The Coin of the Realm”the Realm”

A numerical value (relative reimbursement) A numerical value (relative reimbursement) assigned to a CPT codeassigned to a CPT code

Calculated onCalculated on– Amount of physician workAmount of physician work– Practice expensesPractice expenses– Malpractice costMalpractice cost– Service location (office vs. hospital)Service location (office vs. hospital)

RVU Components of Physician Work

Pre-, intra-, post- service workPre-, intra-, post- service work– Time to perform the serviceTime to perform the service– Technical skill and physical effortTechnical skill and physical effort– Mental skill and judgmentMental skill and judgment– Psychological stress associated with Psychological stress associated with

iatrogenic riskiatrogenic risk

RVUs Cash

RVUs are assigned by the RVUs are assigned by the RRelative elative Value Scale Value Scale UUpdate pdate CCommittee ommittee (RUC)(RUC)

Each 3Each 3rdrd party payer that uses RVus party payer that uses RVus in payment calculations applies its in payment calculations applies its own ‘conversion factor’ (CF)own ‘conversion factor’ (CF)

The CF is multiplied by the RVU to The CF is multiplied by the RVU to determine that payor’s payment determine that payor’s payment

TABLE 2CPT Codes for Developmental Screening

Developmental Screening 96110: Developmental screening96110: Developmental screening

– Limited developmental testing, with interpretation and Limited developmental testing, with interpretation and reportreport

– Expectation is that the screening tool will be completed Expectation is that the screening tool will be completed by a non-physician staff member and reviewed by the by a non-physician staff member and reviewed by the physicianphysician

– No physician work is included in the RVUNo physician work is included in the RVU– Reported in addition to E/M services provided on same Reported in addition to E/M services provided on same

date, with modifier (-25)date, with modifier (-25)– Report for Report for eacheach screen administeredscreen administered– Medicaid may not pay separately for developmental Medicaid may not pay separately for developmental

screening when provided as part of Early and Periodic screening when provided as part of Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT)Screening, Diagnostic, and Treatment services (EPSDT)

Developmental Testing

96111: Extended developmental 96111: Extended developmental testing/evaluationtesting/evaluation– Used for extended developmental Used for extended developmental

testing typically provided by the medical testing typically provided by the medical provider provider

– Includes the interpretation and reportIncludes the interpretation and report– Based on 1 hr of physician workBased on 1 hr of physician work– Reported in addition to E/M services Reported in addition to E/M services

provided on same date, with modifierprovided on same date, with modifier

Evaluation and Management (E/M) Codes

Bill based on level of complexity- 3 Bill based on level of complexity- 3 major componentsmajor components– HistoryHistory– Physical ExamPhysical Exam– Medical Decision Making (MDM)Medical Decision Making (MDM)

Bill based on timeBill based on time– Only if counseling and coordination Only if counseling and coordination

of care > 50% of visitof care > 50% of visit

“Complexity” Billing: HistoryTypeType HPIHPI ROSROS PFSHPFSH

Problem Problem FocusedFocused

Brief (1-3)Brief (1-3) N/AN/A N/AN/A

Expanded Expanded Problem Problem FocusedFocused

Brief (1-3)Brief (1-3) Brief (1)Brief (1)

DetailedDetailed Extended Extended (4+)(4+)

Extended (2-Extended (2-9)9)

Pertinent (1)Pertinent (1)

ComprehensiComprehensiveve

Extended Extended (4+)(4+)

Complete Complete (10+)(10+)

Complete Complete (2/3 or 3/3)(2/3 or 3/3)

Examination Problem FocusedProblem Focused

– Limited to affected body area or organ systemLimited to affected body area or organ system– 1 body area/organ system1 body area/organ system

Expanded Problem FocusedExpanded Problem Focused– Affected body are or organ system and other Affected body are or organ system and other

symptomatic or related organ systemsymptomatic or related organ system– 2-4 body areas/organ systems2-4 body areas/organ systems

• Detailed Detailed – Extended exam of affected body area(s) and other Extended exam of affected body area(s) and other

symptomatic or related organ systemssymptomatic or related organ systems– 5-7 body areas /organ systems5-7 body areas /organ systems

• ComprehensiveComprehensive– Complete single system specialty exam orComplete single system specialty exam or– Complete multi-system examComplete multi-system exam– 8 or more body areas/organ systems8 or more body areas/organ systems

Medical Decision Making

Number of possible diagnoses and/or Number of possible diagnoses and/or management optionsmanagement options

Amount and/or complexity of medical records, Amount and/or complexity of medical records, diagnostic tests, and/or other information that diagnostic tests, and/or other information that must be reviewedmust be reviewed

Risk of complications, morbidity and/or Risk of complications, morbidity and/or mortality, associated with the patient’s mortality, associated with the patient’s presenting problem. Includes need for presenting problem. Includes need for diagnostic procedures and management optionsdiagnostic procedures and management options

Medical Decision Making

Decision Decision MakingMaking

Number of Number of DiagnosesDiagnoses

Amount of Amount of DataData

Risk of Risk of ComplicatiComplicationon

Straight Straight forwardforward

MinimalMinimal Min. or Min. or NoneNone

MinimalMinimal

Low Low ComplexityComplexity

LimitedLimited LimitedLimited LowLow

Moderate Moderate ComplexityComplexity

MultipleMultiple ModerateModerate ModerateModerate

High High ComplexityComplexity

Extensive Extensive ExtensiveExtensive HighHigh

Time Reporting: CPT Counseling Rule

Use when the time spent in ‘counseling and Use when the time spent in ‘counseling and coordination of care’ > 50% of the E&M coordination of care’ > 50% of the E&M visit visit

The 3 key components of history, PE, MDM The 3 key components of history, PE, MDM may be ignoredmay be ignored– Only time is used to select the level of careOnly time is used to select the level of care

A summary of the ‘counseling’ discussion A summary of the ‘counseling’ discussion should be included with the noteshould be included with the note

Does not include screening timeDoes not include screening time– Reported separately, with modifier (-25)Reported separately, with modifier (-25)

Believe me, this is the best way to get paid for visits focused on developmental and behavioral problems

Preventive Medicine Services

E/M services performed in the E/M services performed in the absence of a significant absence of a significant problem/abnormalityproblem/abnormality

Extent and focus depends on the Extent and focus depends on the patient’s agepatient’s age

Included counseling/anticipatory Included counseling/anticipatory guidance/risk factor reductionguidance/risk factor reduction

Preventive Medicine Services

New PatientNew PatientInitial E/M of a new patient including an age and gender Initial E/M of a new patient including an age and gender appropriate history, examination identification of risk factors, appropriate history, examination identification of risk factors, ordering of appropriate tests, and counselingordering of appropriate tests, and counseling

RVU/2003 MedicareRVU/2003 Medicare

– 99381 Age< 1 year99381 Age< 1 year 2.75/$101.162.75/$101.16– 99382 Ages 1-4 years99382 Ages 1-4 years 2.96/$108.892.96/$108.89

Established PatientEstablished PatientPeriodic reevaluation and management requiring an age and Periodic reevaluation and management requiring an age and gender appropriate history, examination identification of risk gender appropriate history, examination identification of risk factors, ordering of studies, and counselingfactors, ordering of studies, and counseling

RVU/2003 MedicareRVU/2003 Medicare

– 99391 Age< 1 year99391 Age< 1 year 2.08/$76.512.08/$76.51– 99392 Ages 1-4 years99392 Ages 1-4 years 2.33/$85.712.33/$85.71

Office Visits-New PatientCodesCodes 9920199201 9920299202 9920399203 9920499204 9920599205

HistoryHistory Problem Problem FocusedFocused

ExpandExpanded ed Problem Problem FocusedFocused

DetaileDetailedd

ComprehenComprehensivesive


ExamExam Problem Problem FocusedFocused


DetaileDetailedd




Straight Straight ForwardForward


Low Low ComplComplexex

Moderate Moderate ComplexComplex

High High ComplexComplex

Time FFTime FF 1010 2020 3030 4545 6060

Key #Key # 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3 3 of 33 of 3

Office Visits-Established Patient

CodesCodes 9921199211 9921299212 9921399213 9921499214 9921599215

HistoryHistory Not Not RequiredRequired



DetailedDetailed ComprehComprehensiveensive

ExamExam Not Not RequiredRequired



DetailedDetailed ComprehComprehensiveensive


Not Not RequiredRequired


Low Low ComplexComplex

Mod Mod ComplexComplex


Time FFTime FF 55 1010 1515 2525 4040


Consultations Consultation is a service provided by a physician Consultation is a service provided by a physician

whose opinion or advice is requested by another whose opinion or advice is requested by another physician or other appropriate sourcephysician or other appropriate source

Consultant may initiate diagnostic and/or Consultant may initiate diagnostic and/or therapeutic servicestherapeutic services

Consultant must document:Consultant must document:

-Request for consultation (written or verbal)-Request for consultation (written or verbal)

-Need for consultation-Need for consultation

-Opinion and services ordered and -Opinion and services ordered and performedperformed

-Communication by written report back to -Communication by written report back to the the referring source referring source

Office Consultation/ New or Est

CodeCode 9924199241 9924299242 9924399243 9924499244 9924599245

HistorHistoryy

ProbleProblem m FocuseFocusedd


DetaileDetailedd

ComprehensComprehensiveive

ComprehComprehen.en.

ExamExam ProbleProblem m FocuseFocusedd


DetaileDetailedd

ComprehensComprehensiveive

ComprehComprehen.en.

DecisiDecision on MakinMakingg

StraighStraight-t-forwarforwardd

StraightStraight--forwardforward

Low Low ComplComplexex

Mod Mod ComplexComplex


Time Time FFFF

1515 3030 4040 6060 8080


Prolonged Services(99354-99359)

Code series defining prolonged services by:Code series defining prolonged services by:– Site of serviceSite of service– Direct or without direct patient contactDirect or without direct patient contact– TimeTime

Reported in addition to other physician Reported in addition to other physician services, including E/M services at any services, including E/M services at any levellevel

• Total time for a given date, even if the time Total time for a given date, even if the time is not continuousis not continuous

• Time must be of 30 minutes or moreTime must be of 30 minutes or more

Prolonged Services

Direct Patient Direct Patient CareCare

OutpatientOutpatient

Face to FaceFace to Face 99354 first 30-74 99354 first 30-74 minmin

Face to FaceFace to Face 99355 each add 99355 each add 30 min >7530 min >75

Before or after Before or after Face to FaceFace to Face

99358 first 30-74 99358 first 30-74 min of non-face min of non-face to faceto face

Before or after Before or after Face to FaceFace to Face

99359 each add 99359 each add 30 min >75 min30 min >75 min

Modifiers

Services altered by specific Services altered by specific circumstance circumstance

Tells insurer “this visit is different”Tells insurer “this visit is different”

--21 Prolonged E/M Service21 Prolonged E/M Service

-25 Significant separately identifiable E/M -25 Significant separately identifiable E/M

Service by the same physician on the same Service by the same physician on the same dayday Used to report developmental screening with E/M Used to report developmental screening with E/M

codecode

-32 Mandated Services-32 Mandated Services

-52 Reduced Services-52 Reduced Services

Documents

Developmental Screening: Billing and Coding Michelle M. Macias, MD D-PIP Training Workshop June 16, 2006 I have no relevant financial relationships with