Stuart B Black MD, FAAN Chief of Neurology Co-Medical ... Lecture... · Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director:

Billing and Coding in Neurology and Headache

Stuart B Black MD, FAAN

Chief of Neurology

Co-Medical Director: Neuroscience Center

Baylor University Medical Center at Dallas

CPT Codes vs. ICD Codes

CPT CodesCategory 1 CPT Codes

Describe a procedure or service identified with a five-digit numeric CPT code and descriptor nomenclature

Used to report physician services: medical, surgical, radiology, laboratory, anesthesiology and E/M

There are approximately 298 E/M CPT codes (99201-99499)

Category 11 CPT Codes

Optional codes developed principally to support performance measurement

PQRS is reported using Category 11 CPT Codes

Category 111 CPT Codes

Temporary codes for emerging technology, services and procedures

ICD Codes▫ Describe signs, symptoms, injuries, diseases and conditions▫ Describes the clinical condition of the patient to support the medical necessity or the

procedure or service (to describe the medical necessity of the CPT code chosen)▫ There are 17,000 ICD-9 Diagnosis Codes

Commonly Used CPT CodesWhen Time Matters

992129921399214992159920499205

10 minutes15 minutes25 minutes40 minutes45 minutes60 minutes



Code Typical Time for Code Threshold to bill 99354 Threshold to bill 99355

New Patient Evaluation 99201 - 99205

Established Patient Evaluation 99211 - 99215

Prolonged Service with Direct Patient Contact 99354 - 99355

If the time equals or exceeds the threshold time for code 99354 , but is less than the threshold time for code 99355, bill the E&M code and 99354.

If the time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, bill 99354 and one unit of code 99355. One additional unit of 99355 is billed for each additional 30 minutes extended duration

Prolonged Service With Direct Patient ContactCase Examples of Using 99354 and 99355

Visit CPT code 99213 (15 min). Total duration of face to face service was 65 minutes. Bill CPT code 99213 and one unit of 99354 (Threshold 45 Min)

Visit CPT code 99212 (10 min). Face to face service was 35 minutes. Cannot bill for prolonged services because the 99354 threshold of 40 minutes was not met

Visit CPT code 99215 (40 min). Face to face service was 75 min of Counseling. Bill CPT code 99215 and one unit of 99354 (Threshold 70 min)

60 minute office visit that was Counseling: Cannot code 99214, which has a typical time of 25 minutes, and one unit of 99354. For Counseling and Coordination of Care, must bill the highest level code in the CPT code family (99215 which has a 40 minutes time units associated with it). If the additional time spent beyond 99215 is 20 minutes and does not meet the threshold time for billing prolonged services (60 minutes with a threshold for 99215 of 70 minutes) can only bill a 99215.

CPT Evaluation and Management CodingNew Patient (3 out of 3)

Code History Exam Medical Decision

Making

99201 Problem focused Problem focused Straightforward

99202 Extended problem

focused

Extended problem

focused

Straightforward

99203 Detailed Detailed Low complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT Evaluation and Management CodingEstablished Patient (2 out of 3)


Making

99211 Minimum services; Physician not required


99213 Extended Problem

Focused

Extended Problem

Focused

Low complexity

99214 Detailed Detailed Moderate Complexity


Defining Evaluation/Management ServicesSeven Components Recognized

1. History

2. Examination

3. Medical Decision Making

4. Nature of the Presenting Problem

5. Consultation

6. Coordination of Care

7. Time

Example CaseHistory: HPI, ROS, PFSH

32 year old woman with PMH of “TTH”. Onset of H/A age 14. H/Aassociated with vomiting, photophobia & dysfunction. The initialheadaches were left hemicranial. 8 year history of chronic dailyheadaches. The headaches are debilitating with a pounding,throbbing quality. Taking hydrocodone/acetaminophen daily(4-6/D) for 5 years; was taking butalbital beforehydrocodone/acetaminophen. Disability for 2 years. New onset:“visual blurring” OD; hypalgesia and possible mild paresis in RUE;transient confusion

Key Components of the HPI

HPI

Elements

(8)

LevelsProblem

Focused

Expanded

Problem

Focused

Detailed Comprehensive

•Location

•Quality

•Severity

•Duration

•Timing

•Context

•Modifying

factors

•Associated

signs or

symptoms

Brief

1-3 elements

Brief

1-3 elements

Extended

4 or more

Elements

Extended

4 or more elements

CategorizationNeurological Single System Examination

1 point General Appearance of Patient1 point Measurement of Any 3 or 7 Vital Signs1 point Ophthalmologic Examination

Cardiovascular Examination1 point Examination of Carotid Arteries1 point Examination of Heart1point Examination of Peripheral Vascular System

5 points possible Higher Cortical Functions8 points possible Cranial Nerves1 point Sensation1 point Muscular Strength1 point Muscle Tone1 point Deep Tendon Reflexes1 point Coordination1 point Gait and Station

Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997

Components of Neurological Examination

Level of Exam 1997 Single Organ System

Problem focused 1-5 elements

Expanded Problem Focused At least 6 elements

Detailed At least 12 elements

Comprehensive Perform all components

Document all elements in

Constitutional

Eyes

Musculoskeletal

Neurological

Document 1 element in

Cardiovascular


Level of Care99201?; 99202?; 99203?; 99204?; 99205?

Physical Exam Exam: 25 Bullets

BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Carotids and PE WNL

Neurological Exam

Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes

Sensation; All WNL

Medical Decision Making

CPT coding provides only descriptive assessments, not numerical values CPT gives no precise quantative standards of measure, for the MDM elements

butMDM asks us to define a quantative assessment using qualitative descriptorsHowever, there are no quantitative values to define the elements of MDM

The MDM Elements Are

The number of diagnosis or management options The amount of data reviewed or orderedThe complexity of data reviewedThe complexity of data orderedThe risk of the presenting problemThe risk of diagnostic procedures oThe risk of management options selected

Medical Decision Making Scoring System

Methodology to determine level of MDM have been developed. There are several systems currently in use.

The scoring guides are based on a point system that takes qualitativeinformation collected by the provider and translates it into quantitative data.More points translate into a higher level of service.

Examples of the scoring systems that follow can be found in the CMS Evaluation And Management Coding and Documentation

Reference Guide and other reliable sources

In general scoring systems are not part of the 1995 or 1997 Evaluation and Management Documentation Guidelines

Medical Decision Making1. Number of Diagnosis and Management Options

Quotes from the 1997 Documentation Guidelines (CMS)

“For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated, or implied in documented

decisions regarding management plans and/or further evaluation.”

“For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved;

or inadequately controlled, worsening, or failing to change as expected.”

“For a presenting problem without an established diagnosis, the assessment may be stated in the form of differential diagnosis

or as a ‘possible‘, ‘probable‘, or ‘rule out‘ (R/O) diagnosis”

Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997

Case ExampleMDM Does Not Ask For The Final ICD Diagnoses

Level of Care99201?; 99202?; 99203?; 99204?; 99205?



Neurological Exam


Sensation; All WNL

Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4.

Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O

Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct)

2. Number of Diagnosis and Treatment options >4

Medical Decision Making2. Amount and/or Complexity of Data to be Reviewed

Data to be reviewed includes: Ordering tests: Reviewing tests and discussion with physicians interpreting tests; direct review and interpretation of actual images, tracings specimens.

Old Records: It also includes obtaining old records for review and documentation of actual findings in the old records.

Document any tests ordered or data reviewed

The type of diagnostic testing ordered, planned, scheduled or reviewed

Review old medical records, lab, radiology and diagnostic tests

Discussion of the case or tests with another physician

Direct visualization of imaging or other tests

Case Example

Level of Care99201?; 99202?; 99203?; 99204?; 99205?



Neurological Exam


Sensation; All WNL


Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O

Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct)

2. Number of Diagnoses and Treatment Options >4

Complexity of

Data Reviewed

Reviewed >4

22 pages of prior records; Head Ct without contrast (2004); CT cervical spine

(2004); EEG (2005); MRI Head (2005)

Ordered >4

MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care?

Medical Decision Making3. RISK

What is meant by “Risk?”Risk of significant complications, morbidity, and/or mortality

Issues to consider and Documentation RecommendationsRisk associated with the presenting problemRisks associated with the diagnostic procedure(s)Risks associated with the possible management problems

Medical Decision Making3. Risk of Complications and/or Morbidity or Mortality

The Table of Risk is published in the 1997 Documentation Guidelines

Risk of the Presenting Problem(s)

Risk of Diagnostic Procedure(s) Ordered

Risk of Management Options

“The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any

procedures or treatment.”

“The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management

options) determines the overall risk.”

Health Care Financing Administration. Documentation Guidelines for Evaluation and Management Services. Chicago, Ill: American Medical Association; 1997.

Case Example

Level of Care99205



Neurological Exam


Sensation; All WNL


Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral

Vascular Disease (TIA, Cerebral Emboli, Infarct)

Complexity of Data

Reviewed

Reviewed

22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004)

Ordered

MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care?

Risk NPP: “…a disease, condition, illness, injury, symptom sign, finding, complaint or other

reason for the encounter, with or without a diagnosis being established at the time of the

encounter”

Using Table of Risk:

“One of more chronic illnesses with chronic exacerbation, progression or side effects of

treatment”

“Abrupt change in neurologic status; seizure, TIA, weakness, sensory loss”

“Drug therapy requiring extensive monitoring for toxicity”

MDM: Qualitative Data into Quantative DataTwo of the Three Components Determine the final Level

Table A1 (and A2)Number of Diagnosis and Management OptionsAdd up the points for the totalMay use the larger of Table A1 or A2 for total MDM

Table BData Reviewed or OrderedAdd up the points for the total

Table CLevel of RiskThe final Risk is the highest of the three Risks from the Table of Risks

Table DFinal level of MDMRequires that two of the three components are met or exceeded

CMS E&M Coding and Documentation Reference GuideTables A1 and A2

Table for Management Options: Table 1A

Examples of commonly prescribed treatments

One (1) point value is the most common designation for most treatments.

Table 1A, Number of Diagnoses is most commonly used

Number of Diagnoses and Management Options: (Table 1B)

Difficult to have specific table that is all inclusive for Management Options

“Continue the same therapy” or “no change in therapy” do not count unless specific therapy is described, documented or reviewed.

Drug doses for current medications are not required, however, the record must reflect conscious decision making to make no dose changes in order to count for coding purposes.

Medical Decision Making Scoring SystemTable A1:Number of Diagnoses or Treatment Options.

Number of Diagnoses or Treatment Options Points

Each new or established problem for which the diagnoses and/or

treatment plan is evident with or without diagnostic confirmation1

Two plausible differential diagnoses, comorbidities or complications

(not counted as separate problems) clearly stated and supported by

information in the record: requiring diagnostic evaluation or

confirmation2

3 plausible differential diagnoses, comorbidities or complications (not

counted as separate problems) clearly stated and supported by

information in the record: requiring diagnostic evaluation and

confirmation3

4 or more plausible differential diagnoses, comorbidities or

complications (not counted as separate problems) clearly stated and

supported by information in the record: requiring diagnostic evaluation

and confirmation4

Total 4

Management Options: Table A2Table A2 could never by all inclusive; following are examples

Do not count as treatment option’s notations such as: “Continue same therapy “ or “no change in therapy” if specific therapy is not described 0

Drug management includes “same therapy” or “no change ≥3 new/current meds In therapy if specific therapy is described. The record mustreflect conscious decision-making for coding purposes >3 new/current meds

1

2

Physical therapy, occupational or speech therapy 1

IV fluids, such as infusion in infusion center 1

Conservative measures such as rest, diet, etc 1

Discuss case with another physician or admit to hospital 1

CMS E&M Coding and Documentation Reference GuideTable B: Data Reviewed or Ordered

Order and/or review medically reasonable and necessary clinical laboratory procedures

1-3 procedures≥4 procedures

1 point 2 points

Order and/or review medically reasonable and necessarydiagnostic imaging studies in Radiology section of CPT


1 point2 points

Order and/or review medically reasonable diagnostic procedures in Medical section of CPT


1 point2 points

Discuss test results with performing physician 1 point

Discuss case with other physician(s) involved in patient’s care or consult another physician; does not include referring patient to another physician for future care 1 point

Order and review old records. Record type and source must be noted. Must be tied to patient care protocol

No summaryWith summary

1 point2 points

Independent visualization & interpretation of image/ test for MDM. Each visualization & interpretation is a point 1 point

Review of physiologic monitoring or testing data. 1 point

Total points 4 points

CMS E&M Coding and Documentation Reference GuideTable C:Risk of Complications &/or Morbidity or Mortality

1. Minimal (level 1) 2.Low (level 1 3. Moderate (level 2) 4 high (level 3)Final Risk determined by highest of 3 components below

Risk of presenting problem(Risk of morbidity, mortality, comorbidities, or complications with prolonged functional impairment)

1. min 2. low 3. mod 4. high

Risk of diagnostic procedure(s) ordered or reviewed


Risk of management options selected


Table D: Assignment of Medical Decision Making2 of 3 components in table D must be met or exceeded

A. Number of diagnoses or management options

1 PointMinimal

2 PointsLimited

3 PointsMultiple

≥4 PointsExtensive

B. Amount and complexity of data reviewed / ordered

≥1 PointNone/Minimal

2 PointsLimited

3 PointsMultiple

≥4 PointsExtensive

C. Risk Minimal Low Moderate High

Type of Medical Decision Making Straight-Forward

Low Complexity

ModerateComplexity

HighComplexity

CPT Evaluation and Management CodingNew Patient (3 out of 3)


Making


99202 Extended problem

focused

Extended problem

focused

Straightforward

99203 Detailed Detailed Low complexity

99204 Comprehensive Comprehensive Moderate Complexity


Consultation and Coordination of CareTIME

In certain circumstancesTIME

Is the controlling factor in determining the level of an E/M service

“Intraservice times are defined as face-to-face time for office and other outpatient visits…”

The amount of time spent becomes the sole determining factor of the level of the E/M code

This is true of the exam and MDM components which do not need to be performed


Time determines the level of E/M service when counseling and/or coordination of care

dominates > 50% the encounter

Counseling and coordination is separate from the history, physical exam and medical decision making

Consultation and Coordination of Care is a common scenario for Established Patient visits for Neurologists and

Headache specialists

The extent of consultation and/or coordination of care must be documented in the medical record independent of the

three key components

Consultation and Coordination of CareTime

Counseling patient and/or family documention (2013)Diagnostic results, impressions, and/or recommended studies

Prognosis

Risks and benefits of management or treatment options

Instructions and /or follow up

Importance of compliance with chosen treatment and management options

Instructions and/or follow-up

Risk factor Reduction

Patient and family education

Note on ‘Average Times’ For Consultation and Coordination of Care Times listed in the CPT code book are “average times” associated with

each CPT code. Auditors often treat them as threshold times

Ex: A 99214 has an average time of 25 minutes. Although not in the

Documentation Guidelines, an auditor usually interprets 25 minutes or

more supporting 99215, but less than 25 minutes not supportive of 99214

American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2013


American Headache Society (AHS) AHS’s Headache Coding Corner

http://www.americanheadachesociety.org/professionalresources/AHSsHeadacheCodingCorner.asp

American Medical Association CPT-related resources

http://www.ama-assn.org/ama/pub/category/3113.html

Centers for Medicare and Medicaid Service (CMS) Evaluation and Management Services Guide

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

1997 Documentation Guidelines for Evaluation and Management Serviceshttp://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

http://www.americanheadachesociety.org/professionalresources/AHSsHeadacheCodingCorner.asp

http://www.ama-assn.org/ama/pub/category/3113.html

Documents

Stuart B Black MD, FAAN Chief of Neurology Co-Medical ... Lecture... · Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: