Upload
brianne-doughtie
View
225
Download
4
Tags:
Embed Size (px)
Citation preview
Hospitalist Coding and Billing (For Dummies)
Judith Hooffstetter, MD
Hospitalist
Objectives
Describe basics of coding and billing
List documentation requirements for E/M levels
Explain new consultative codes
Anatomy of a Charge Card
H&P OBS Subsequent F/U
Admitting
99221 99218 99231 AI
99222 99219 99232
99223 99220 99233
DX ICD-9 Code
Acute on Chronic CHF 428.23
A fib 427.31
DMII Uncontrolled 250.0
Hypothyroid Stable 246.9
COPD 496.0
ICD-9 and CPT Relationship
CPT codes explain WHAT service was performed (level of visit or procedure)
ICD codes explain WHY the service was performed (the diagnosis)
ICD-9
Classification based system that groups data into broad categories
Required by the World Health Organization for reporting mortality data for comparison across countries.
ICD-9 CM is a modification of the code and has been used in the US since 1979.
Anatomy of ICD-9 CM
Have 3,4 or 5 numeric or alpha numeric codes
17 main division of chapters and then further broken down into code sections, code categories, code subcategories and code subclassifications.
The more numbers, the more specific
427427.4
427.41
Cardiac dysrhythmia
Ventricular fibrillation and flutter
Ventricular fibrillation only
Current Procedural Terminology
(CPT)
CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.
CPT Codes for Hospitalists
Admit and Consult Codes99221- 99223
Subsequent Follow Up 99231-99233
Critical Care Codes99291-99292
Extended Time Codes99356-99357
Discharge Codes99238-99239
How You Get Paid!!
Admission Codes for Hospitalists CMS
99221 – 99223
+
AI (admission modifier)
Elements for E&M visits (How you document for the level)
History – CC – HPI– ROS – PFSH (past, family, social history)•
Exam – number of organ systems
Decision making – #diagnoses or management options – Amount of data/complexity – risk level to patient
Inpatient Level of Care
Key Components
99221 99222 99223
Patient History Detailed Comprehensive
Comprehensive
Patient Exam Detailed Comprehensive
Comprehensive
Medical Decision Making (MDM)
Low Moderate High
For H&P 3 of 3 key elements need to be met
Subsequent Level of Care
Key Components
99231 99232 99233
Patient History Problem focused
Expanded Problem Focused
Detailed Interval
Patient Exam Problem focused
Expanded Problem Focused
Detailed
MDM Straightforward
Moderate High
Subsequent Care requires 2/3 elements
History Matrix
Type of History
HPI ROS FH/SOC Hx
Problem focused
Brief (1-3 elements)
n/a n/a
Exp Problem Focused
Brief (1-3) Problem Pert.(1 system)
n/a
Detailed Extended (4 elements or status of 3 chr
Extended (2-9 systems)
Pertinent (1 element)
Comprehensive
Extended Comprehensive (10 system)
Complete 3/3
ROS
Must Note Pertinent Positives and Negatives in at least 10 systems for Comprehensive
Can no longer say all ROS negative (Can refer to check list on written guide)
Can say unable to obtain from patient (if patient obtunded etc).
Organ Systems (1997 Guidelines)
Cardiovascular
Respiratory
Ear, Nose, and Throat
Eye
Genitourinary
Hematologic/Lymphatic/Immunologic
Musculoskeletal
Neurological
Psychiatric
Skin
Patient Exam
Type of Exam Required PE
Problem Focused 1 – 5 bullets (or one body system or organ system)
Expanded Problem Focused 6 bullets (2-4 body areas or organ systems)
Detailed At least 2 bullets from specified systems or 12 bullets (5-7 body areas or organ systems)
Comprehensive 18 elements with at least 2 from each system (8+ body areas or organ system)
Medical Decision Making Matrix
Type of Decision Making
Number of Diagnosis
Amount and complexity of data
Risk of Complication or Morbidity or Mortality
Straightforward
Minimal (≤1) Minimal (1) or none
Minimal
Low Limited (2) Limited (2) Low
Moderate Multiple (3) Moderate (3) Moderate
High Extensive (≥4) Extensive ≥4 High
MUST MEET 2/3 COMPONENTSFinal MDM requires that 2 of 3 above components are met or exceeded
Amount and complexity of data
Action Points
ReviewAnd/or order clinical test (labs)
1 point
Review and/or order of radiology
1 point
Review and/or order of medical test (vaccines, echo, ekg, pft)
1 point
Discussion of test with performing MD
1 point
Independent review of test 2 points
• Old records or hx from another person and summarizing
2 points
Moderate Complexity
One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast
Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness
Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors
High Complexity
One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function,
An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss
Cardiovascular imaging studies with contrast with identified risk factors
Elective and emergency major surgery
Parenteral controlled substances or drug therapy requiring intensive monitoring for toxicity
Pearls
Action Level
Prescription drug management moderate
2+ stable chronic illness moderate
Abrupt MS change (seizure, TIA)
high
1 chronic illness w/severe exacerbation, progression
high
Make DNR high
Cardiovascular imaging studies with contrast with identified risk factors
high
Emergent major surgery high
Parenteral pain medication high
Subsequent Level of Care
Key Components
99231 99232 99233
Patient History Problem focused
Expanded Problem Focused
Detailed Interval
Patient Exam Problem focused
Expanded Problem Focused (6)
Detailed (12)
MDM Straightforward
Moderate High
Subsequent Care requires 2/3 elements
Time Based Coding for Subsequent Care
When counseling/coordination of care is > 50% of service
AND
When TIME based code would be higher level of service
Time Based Code
CPT CODE Time
99231 15 minutes
99232 25 minutes
99233 35 minutes
Inpatient Consults
Request for consult must be documented by requesting and completing physician
Consulting physician must document opinion and/or advice (send cc to requesting physician)
Document the problem for which YOU are seeing the patient (to prevent concurrent care denials)
Document time = total time
Consults Codes (CMS)
99221- 99223
Consult Codes
No longer use consult codes (99251-99255) for CMS
Can still use them for commercial payers
Use admission codes 99221-99223 (but without the AI modifier).
Can use prolonged service codes (99356-99357) if applicable
Crosswalk for Inpatient ConsultsOld CPT History Exam MDM New code
99253 Det Hx Det Exam At least 2 bullets from specified systems or 12 bullets
Low 99221
99254 Comp Hx 18 elements with at least 2 from each system
Moderate 99222
99255 Comp Hx 18 elements with at least 2 from each system
High 99223
Prolonged Service Codes 99356-99357
Greatly increases reimbursement
Use with 99232 and 99233 when appropriate
Never use with 99231
CAN BE A FLAG FOR MEDICARE AUDITS – so must be used appropriately and well documented
Discharge Codes
99238 Used when time is less <30 minutes
99239Used when time is less >30 minutesMUST DOCUMENT IN YOUR
DICTATION TIME SPENT
TO RECAP
Inpatient Admission Level 3
Component Level 3 Requirements
History Comprehensive
Exam 18 elements with at least 2 from each system
MDM High
Subsequent Visit Level 2
Component Service Required
Exam Problem focused - 6 bullets
MDM Moderate
OR
DOCUMENT BASED ON TIME
Subsequent Visit Level 3
Component Required
Exam 18 elements with at least 2 from each system
MDM High
OR
BASED ON TIME
?