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1



Coding for Local Health
Department Clinic & School Sites


July 18,
2013


Presented by: Cynthia H. Robinson

Internal Policy Analyst
III

Table of Contents

1.
Coding on the PEF

2.
Determination of New or Established Patients

3.
Coding of Preventive Visits

4.
Components for coding “Other than Preventive
E/M Visits”


Problem Visits

5.
Coding of Problem Visits
-
New Patients

6.
Coding of Problem Visits
-
Established Patients

7.
Multiple Visits for the Same Patient on the
Same Day

2


This presentation was done to aid
employees of health department clinics in
coding and reporting of services. It could
not possibly cover all of the circumstances
which occur in these clinics on a day to day
basis. This presentation is intended to
assist in the training of new employees and
to refresh existing employees.


3

Guiding Principles

1.
Only provide the level of care that is
medically necessary per clinical judgment.

2.
Always provide and document services in
accordance with the Core Clinical Service
Guidelines (CCSG) and with established
best practices.

3.
Always code and document exactly what
care was provided.


4




Coding on the Patient
Encounter Form (PEF)

5

6

Coding on the PEF


The state
-
updated CH
-
45 (PEF) is used in most
health department clinics.


Some health departments prefer to create and use
an abbreviated PEF at off site clinics (e.g. Flu
Clinics & School sites). This is entirely
permissible.


Health Departments using their own forms are
responsible for keeping these forms up
-
to
-
date.

Codes

7

Current Procedural Terminology (CPT)


A set of codes,
descriptions, and guidelines intended to describe
procedures and services

performed by physicians
and other health care providers.

CPT codes describe WHAT was done for the patient.

International Classification of Disease 9
th

Revision 2009
(ICD
-
9)


This system is required for reporting
diagnoses and diseases

to all U.S. Public Health
Service and Department of Health and Human
Services Programs, such as Medicare and Medicaid.

ICD
-
9 codes describe WHY it was done.


8

Examples of Codes

CLINIC SETTING:


99211


Office or other
outpatient visit for the
evaluation and management of
an established patient that may
or may not require the presence
of a physician.


99393


Periodic
comprehensive preventive
medicine


reevaluation &
management of an individual
late childhood (age 5 through 11
years)





V741


Special Screening
Examination
for
Pulmonary
Tuberculosis /
Z11.1
-
Encounter
for screening for respiratory
tuberculosis



V202
-

Routine
Infant Or Child
Health
check/ Z00.129
-
Encounter
for routine child health
examination without abnormal
findings





CPT codes
-

WHAT

ICD
-
9/ICD
-
10
codes
-

WHY

9

Coding E/M visits in health department
clinics consists of:


Preventive Visits E/M visits (e.g. well child
exam, well woman checks)


Evaluation/Management visits, which
LHD’s commonly refer to as “problem
visits” (e.g. supply visits, STD’s, cancer
screenings)

Coding E/M visits on the PEF

10


Preventive Visits (e.g. Well Child Exams)


Top left corner of PEF


Coding on the PEF


Other E/M Visits (Problem Visits)


Top right corner of PEF


11

Coding on the PEF

12


REMEMBER:


992 codes
-

for use by physicians and mid
level providers only


W92 codes
-

for use by nurses (RN’s)


Coding on the PEF


Provider Level



Physicians and mid level providers
code in the upper portion of the
Preventive and Other Than Preventive
Sections.



Nurses code in the lower portion of
the Preventive and Other Than
Preventive Sections.

13

Coding on the PEF
-

CPT codes


CPT codes for lab tests, etc. that are done as part of the
visit must be....


Checked in the appropriate

box on the PEF





OR, if the service is not listed on the PEF it should be
written in the area provided on the back of the PEF

Coding on the PEF
-

ICD codes


ICD codes need to be written on the PEF in
the section that corresponds with the service
that was provided.


ICD codes will reflect
why

the patient
presented. They are assigned based on the
presenting problem(s) of the patient.


REMEMBER: ICD codes for LHDs must be
five digits. If the code is 3 or 4 digits, add
dashes to make the code 5 digits long.
ICD
-
10 will have 3
-
7 characters.

14

Coding on the PEF
-

ICD codes


There is a box for a primary (P) ICD and a secondary
(S) if needed.


For example...a 4 y/o established patient, receives
preventive exam by a nurse (V202
-
/Z00.129) and also
receives vaccines (V069
-
/Z23).


This would be coded on the preventive side of the
PEF

15

V069/

Z23

V202/

Z00.129




16

ICD Codes In Health Department Sites

ICD codes are revised annually and are effective on
October 1 of each year.

ICD9 is changing to ICD10
effective October 1, 2014.

Many LHDs create their own listing of most
commonly used ICD codes.

REMEMBER: These lists must be updated
annually.

Determination of New or
Established Patients

17

18

New & Established Patients

The Patient Encounter Form (PEF or CH
-
45) distinguishes between
New Patients

and
Established Patients
:



New Patients

visits are coded in the areas highlighted in PINK.



Established Patients

visits are coded in the areas highlighted in BLUE.

New & Established Patients


NEW PATIENT
-

a patient who has not
received a professional service (i.e.,
preventive, problem focused, or procedure)
at any health department or satellite clinic
in the COUNTY within the past three years.


Determination of new or established status
is made on a COUNTY basis, not a district
basis.

19

New & Established Patients


The CMS (Clinic Management System)
determines whether the patient is new or
established at computer registration when
the PEF label is created.


The computerized registration process is
generally not done at the satellite site itself,
often making it difficult for the provider to
know whether the patient is new or
established.


20

New & Established Patients


If the provider cannot determine whether
the patient is new or established by looking
at the medical record, the provider should
check the appropriate new patient level of
visit and the appropriate established patient
level of visit on the PEF. (See examples on
next two slides.)


This will save time for the provider and for
staff doing the data entry. The PEF will not
need to be sent back to the nurse for
determination of level of visit.

21


New & Established Patients

Clinic Setting:
If the system is down or off
-
site




Patient presents to nurse requesting pregnancy test:









Staff doing data entry should look at label to determine if it
is a new patient or established, then...


Enter correct office visit


Mark through other visit

22

V7241







New & Established Patients


Under NO circumstances should staff
entering data change the level of visit to
accommodate a new or established patient
status (unless that level was also marked on
the PEF, as discussed in the previous slides).


The
provider

must

determine the level of
visit.

23

Coding of Preventive Visits

24

Coding of Preventive Visits

Preventive visits are reported when the patient
receives a full preventive physical exam per the
guidelines in the Core Clinical Service Guidelines
(CCSG).

Coding of these visits require three components:


New or established patient status


Age of patient


Completion of physical exam by protocols which
are listed in the CCSG

25

Components for coding “Other
than Preventive E/M Visits”

26

Commonly Referred to as
“Problem Visits” in Health
Department Settings

Components of Problem Visits


Problem Visits are made up of three components which
are directly linked to the coding of these services.

1.
History
-
consists of a combination of three parts:


History of present illness


Review of systems


Past, family and social history

2.
Exam

3.
Decision making


These three components are the driving forces behind
the coding of Problem Visits.


Understanding these three components is extremely
important in accurate coding of problem visits.

27

History


Subjective


documentation that is reported by the
patient.


Comparable to the “S” (subjective) portion of the
SOAP note


Combination of three components




History of present illness


what the patient reports as
problems, symptoms, time frames, etc.


Review of systems


what body systems are affected by
the presenting problems


Past, family and social history


what past, familial or
social influences there might be on the seriousness and
resolution of the problem

28

Exam


Objective


what the provider notes when assessing
the patient


The exam is comparable to the “O” (objective) portion
of the SOAP note


The exam portion will be discussed in detail in the
Coding of

Problem Visits
-

New Patients
section of this
presentation


29

Decision Making


The decision making component consists of
three parts...

1.
Presenting problem management options


Comparable to the “A” (assessment) portion of a SOAP
note.


After looking at the patient history and performing exam
as needed, the assessment of what the patient’s
problem(s) are


30

2.
Diagnostic procedures ordered


Provider must decide what, if any, diagnostic
procedures should be done

3.
Management options selected


What treatment the patient should receive


The last two parts combined are comparable to the
“P” (plan) portion of a SOAP note

31

Decision Making

Coding of Problem Visits


32


New Patients


American Medical Association (AMA) rules
require

that you
have documented some of each of these components for new
patients:

1.
History

2.
Exam

3.
Decision making


The AMA rules state that you must code Other E/M Office
Visits for new patients to the lowest of these three
components. By lowest of these three components, they mean
the component which has the least impact on the visit.


Should you be missing one of the three components on a new
patient, an 80000 code will have to be used.


This code gives you no reimbursement and no Work Resource Based
Relative Values. So the time spent with this patient will be as though it
never happened.

33

Coding of Problem Visits



New Patients


The exam component will be the lowest of the three
components 99% of the time.


New patients should be coded by the amount of exam
performed (which are commonly referred to as “exam
bullets” because this is how they are identified in CPT
classification).

34

Coding of Problem Visits



New Patients

35

Exam


New Patients


A complete list of exam bullets can be found
in the
1997 Documentation Guidelines for
Evaluation & Management Services
(
developed

jointly by the AMA & HCFA)
.

Exam


New Patients


CLINIC



The five most common bullets are:


General Appearance/Nutritional Status. (Although these appear on two
lines of the HP/CH
-
13 and HP/CH
-
14 exam forms, they only count as one
bullet.)


Mood and Affect


Orientation


Skin (2 bullets possible)


Inspection


looking (e.g. pink, tan, intact)


Palpation
-

touching (e.g. warm, dry)


Vital signs can be used as an exam bullet also,
but
three

vital
signs from the following list
MUST

be done for it to count as a
bullet
:


Sitting or standing blood pressure


Supine blood pressure


Height


Weight


Temperature


Pulse


Respiration

36


Following is a list of the number of exam bullets that
corresponds to the level of office visit to code for new
patients:


1 to 5 exam bullets = 99201 or W9201 Brief


6 to 11 exam bullets = 99202 or W9202 Expanded


12 to 17 exam bullets = 99203 or W9203 Detailed


18 to 23 exam bullets = 99204 or W9204 Comprehensive


A comprehensive office visit has the same requirements as full
preventive visit (per the preventive guidelines in the CCSG). If this
level of exam is performed, the provider should look at coding a full
preventive exam on the patient.


24 or more bullets = 99205 or W9205 Complex


Comprehensive and Complex levels of new patient visits should
seldom occur in a health department site. These have been addressed
here in case of rare emergencies.

37

Coding of Problem Visits



New
Patients
-

CLINIC

38

Coding of Problem Visits



New Patients
-

CLINIC


The AMA expects medical providers to do a
more thorough exam,
within reason
, on a
new patient to provide a good base line for
future visits (see
907 KAR 3:130
).


Remember to have some History, some
decision making, however the
Coding

for
new

patients is directly related to the
amount of
exam bullets
performed, as it’s
usually the lowest component in HD.


Count the number of exam bullets and code
accordingly.

39

Coding of Problem Visits



New
Patients
-

CLINIC

Coding of Problem Visits

New Patients
-

SCHOOL


According to the new Coding Criteria for
Coordinated School Health: Registered Nurses or
other health dept. personnel may
only

code:



W9201 & W9202


Count the amount of Exam Bullets provided
as
medically necessary and code one of the two
permissible billable codes listed above



40

Coding of Problem Visits


Established Patients

41


To code a Problem Visit for an established patient,
the AMA requires that only
two

of the three
components be documented.

1.
History

2.
Exam

3.
Decision making


The visit should be coded by the lowest of the two
components.

42

Coding of Problem Visits


Established Patients


The level of visit chosen for established
patients will be driven by the lowest of
either the history component or the medical
decision making component.


Exam performed should be what is required
by protocol and medically necessary.

43

Coding of Problem Visits


Established Patients

Coding of Problem Visits


Established Patients (Clinic)



99211 and W9211 Brief



No history is taken



Decision making is minimal



No ROS (review of systems)


Examples:



Negative TB skin test reading



(NEVER write a SOAP note for a negative TB
skin test reading. That raises the level of visit
and is never medically necessary.)



44

Coding of Problem Visits


Established Patients (Clinic)


99212 or W9212 Limited


Requires at least 2 of these 3 key components;




Problem focused history;


Straight forward decision making;


Problem focused exam


Patients who have one or more self
-
limited or minor
problem(s)


Examples


Supply Visit (no complaints or problems)


STD Visit (no problems or negative results)


Head lice (either suspected or found)





45

Coding of Problem Visits


Established Patients (Clinic)


99213 or W9213 Expanded


Requires at least 2 of these 3 key components;


Expanded problem focused history;


Expanded problem focused examination;


Decision making of low to moderate complexity


Examples


Pt

to receive
depo



wt

gain 5
lb

since last visit,
c/o occasional headaches

counseled &
depo

adm.


Positive TB skin test reading


Positive STD visit with treatment



46

Coding of Problem Visits


Established Patients (Clinic)


99214 or W9214 Detailed


Requires at least 2 of these 3 key components;


Detailed history;


Detailed examination;


Decision making of moderate complexity


Presenting problems are of moderate to high complexity


Examples


True

contraindication to contraceptive methods


OCs
-

B/P 160/92, c/o severe HA’s daily with visual impairment
-

no
contraceptive given until patient is further evaluated


Patients presenting with problems significant enough that more case
management is necessary


Pt

with abnormal breast exam

*******Please keep in mind:
907 KAR 3:010 Section 4



PHYSICIAN’S MEDICAID only

pays Doctors for




TWO

99214 visits every 12 months







47

Coding of Problem Visits


Established Patients (Clinic)


99214 or W9214 Detailed


Requires at least 2 of these 3 key components;


Detailed history;


Detailed examination;


Decision making of moderate complexity


Presenting problems are of moderate to high complexity



Example:
Positive
Preg

test


initial PN Visit


-

HIGH RISK PREGNANCY
-

includes



2 or More RISK Factors

See below for RISK Factor examples:

-

History
of Miscarriage/High Blood Pressure/Early

labor
-

Preeclampsia

-

STI with pregnancy


-

Smoker
-

Obesity
-

Age (under or over)




48

Coding of Problem Visits


Established Patients (Clinic)


99215 or W9215 Comprehensive


Requires at least 2 of these 3 key components:


Comprehensive history;


Comprehensive examination;


Decision making of high complexity


Presenting problems are of moderate to high complexity


Significant risk to the life of the patient



Examples


HIV


Rape


Abrupt neurological changes


Anaphylactic reaction to vaccine


Emergency treatment necessary via EMS

*******Please keep in mind:

907 KAR 3:010 Section 4


PHYSICIAN’S MEDICAID only

pays Doctors for





TWO

99215 visits every

12 months




49

Coding of Problem Visits


Established Patients (School)



99211 and W9211 Brief



No history is taken



Decision making is minimal/ low severity/acuity



No ROS (review of systems)

Patients
who have

simple self
-
limited or
minor
problem(s) according to Coding Criteria for Coordinated
School Health

Examples:


Vomiting/diarrhea / Upper respiratory
symptoms / Headache / Sprain / Strain / Bites / Blood
Glucose with carb counting / Seizure disorder / Asthma /
Allergies / Sterile dressing and soaks / Collecting and/or
performance of tests


blood glucose, urine glucose,
pregnancy testing
/







50

Coding of Problem Visits


Established Patients (School)


99212 or W9212 Limited


Requires at least 2 of these 3 key components;




Problem focused history;


Straight forward decision making; complex
severity/acuity


Problem focused exam;

Patients who have more complex

self
-
limited or minor
problem(s) according to Coding Criteria for Coordinated
School Health


Examples:
Vomiting/diarrhea / Upper respiratory
symptoms / Headache / Sprain / Strain / Bites
/
Diabetes / Seizure
disorder / Asthma / Allergies /
Sterile dressing and soaks
/ Follow
-
up for acute
illnesses and injuries




51



Multiple Visits for the Same Patient
on the Same Day

52



A 25 modifier may be reported with a Preventive visit, if there is a significant enough and
separately identifiable problem . The 25 modifier would be listed with problem
-
focused
E/M visit.


When immunizations are given, problem
-
focused E/M with a 25 modifier may be
reported if there is a distinct and separately, identifiable reason for the E/M visit (i.e., a
different diagnosis code).


When an E/M is reported on the same day as another procedure , such as a MNT; the
E/M will require a 25 modifier and the diagnosis code for the E/M needs to different from
the diagnosis code for the MNT.





53

The 25 modifier is located beneath the
Other
Than
Preventive codes section.


You may either check or circle the 25.

Multiple Visits for the
Same

Patient on
the
Same

Day with
Different

Problem
(Clinic)

OTHER THAN

PREVENTIVE HEALTH CHECK E/M
-
PHYSICIAN/MID LEVEL



CPT NEW Visit Type



CPT EST. Visit Type

PROVIDER

99201 Brief

99211 Brief

99202 Expanded

99212 Limited

99203 Detailed

99213 Expanded

99204 Comprehensive

99214 Detailed

ICD (P)

99205 Complex

99215 Comprehensive


25 MODIFIER Separate E/M by same provider/same day





NURSE

ICD (S)

W9201 Brief

W9211 Brief

W9202 Expanded

W9212 Limited

W9203 Detailed

W9213 Expanded

REF/DISP

W9204 Comprehensive

W9214 Detailed

W9205 Complex

W9215 Comprehensive

Example of when to use the

25 Modifier: (Clinic)


39 year old established
pt

comes in for Family
Planning preventive visit, while doing this
pt’s

family planning preventive visit, the APRN
finds vaginal warts, and with the permission of
the
pt
, treats.

Coding would consist of:





99395





9921325



54

Another Example of when to use
the 25 Modifier: (Clinic)


17 year old established
pt

comes in for family
planning supplies and RN finds out she has
not received the Gardasil vaccine.
Pt

wants
to receive this vaccine and is counseled per
component.


Coding would consist of:






W921225






90460





90649


55

PEF Changes for 2013



90718
-

TD has been deleted, Due to all
vaccines being preservative free.


90714 is the correct CPT Code to use for TD



J1055
-
Depo was Deleted, and replaced with
J1050
-
Depo.

56

PEF Changes for 2013

Lab CPT Codes added to the PEF, for easier
access:



86780 x 2units


Syphilis testing, if positive
on VDRL


state lab will inform LHD of this
testing.


86803


Hepatitis C Antibody



57

Guiding Principles



1.
Only provide the level of care that is
medically necessary.

2.
Always provide and document services in
accordance with the Core Clinical Service
Guidelines (CCSG) and with established
best practices.

3.
Always code and document exactly what
care was provided.


58

References:


1)
Current Procedural Terminology 2013

2)
International Classification of Disease 9
th

Revision 2012


3)
1995 CMS document: Documentation Guidelines to
Evaluation & Management Services

4)
1997 CMS document: Documentation Guidelines to
Evaluation & Management Services

5)
CMS Evaluation & Management Service Guide

6)
DPH Policy: Coding Criteria for Coordinated School
Health



59

Recent CDP System Updates by:
Sharon Trivette/Nellie Ramsey


(6/3/2013)
Claim
Processor was
updated to
allow the coding and billing of:



NDC data


CPT
Modifier updated


Four (4) modifiers can be
submitted on a
claim


Modifier override with letter “M”


Extra modifiers required by different payers can be
entered in override area per CPT code.


Prior
Authorization Code
“A”


Prior Authorization numbers are entered with “A” and
the number in override area.


National Drug Code


This is a National Requirement and the claim will deny
without it. It is used with most injectable/implantable
drugs such as DEPO, Rocephin and Mirena IUD.
Vaccines are NOT included
at this time
.


Must be 11 characters submitted in 5
-
4
-
2 format


If not 11 characters, then populate with leading zeros


XXXX
-
XXXX
-
XX=0XXXX
-
XXXX
-
XX


XXXXX
-
XXX
-
XX=XXXXX
-
0XXX
-
XX


XXXXX
-
XXXX
-
X=XXXXX
-
XXXX
-
0X

NDC

NDC PEF Entry


The nurse should indicate the NDC on the vial
including the dashes. If the number is missing a digit
of the format, insert the leading zero in the
appropriate space.


Support Staff will enter the 11 digit NDC number in the
Override Area preceded with the letter “F” with no
dashes.


Example: vial says 0009
-
0746
-
30


Nurse inserts leading zero
0
0009
-
0746
-
30


Support Staff enters “F00009074630” in override


Questions:




Email:
Localhealth.helpdesk@ky.gov



Phone: 502
-
564
-
6663 Option 1



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