1 Coding for Local Health Department Clinic & School Sites
July 18, 2013 Presented by: Cynthia H. Robinson Internal Policy
Analyst III
Slide 2
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
Slide 3
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
Slide 4
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
Slide 5
Coding on the Patient Encounter Form (PEF) 5
Slide 6
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.
Slide 7
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.
Slide 8
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 - WHATICD-9/ICD-10 codes -
WHY
Slide 9
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 LHDs commonly refer to
as problem visits (e.g. supply visits, STDs, cancer screenings)
Coding E/M visits on the PEF
Slide 10
10 Preventive Visits (e.g. Well Child Exams) Top left corner of
PEF Coding on the PEF
Slide 11
Other E/M Visits (Problem Visits) Top right corner of PEF 11
Coding on the PEF
Slide 12
12 REMEMBER: 992 codes - for use by physicians and mid level
providers only W92 codes - for use by nurses (RNs) 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.
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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.
Slide 17
Determination of New or Established Patients 17
Slide 18
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.
Slide 19
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
Slide 20
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
Slide 21
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
Slide 22
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
Slide 23
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
Slide 24
Coding of Preventive Visits 24
Slide 25
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
Slide 26
Components for coding Other than Preventive E/M Visits 26
Commonly Referred to as Problem Visits in Health Department
Settings
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
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
patients problem(s) are 30
Slide 31
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
Slide 32
Coding of Problem Visits 32 New Patients
Slide 33
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
Slide 34
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
Slide 35
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).1997
Documentation Guidelines for Evaluation & Management Services (
developed jointly by the AMA & HCFA)
Slide 36
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
Slide 37
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
Slide 38
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).907 KAR 3:130
Slide 39
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 its usually the lowest component in HD.
Count the number of exam bullets and code accordingly. 39 Coding of
Problem Visits New Patients - CLINIC
Slide 40
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
Slide 41
Coding of Problem Visits Established Patients 41
Slide 42
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
Slide 43
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
Slide 44
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
Slide 45
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
Slide 46
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
headachescounseled &depo adm. Positive TB skin test reading
Positive STD visit with treatment 46
Slide 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
Examples True contraindication to contraceptive methods OCs - B/P
160/92, c/o severe HAs 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 PHYSICIANS MEDICAID only pays
Doctors for TWO 99214 visits every 12 months 47
Slide 48
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
Slide 49
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 PHYSICIANS MEDICAID only pays Doctors
for TWO 99215 visits every12 months 49
Slide 50
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
Slide 51
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
Slide 52
Multiple Visits for the Same Patient on the Same Day 52
Slide 53
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 TypePROVIDER 99201 Brief99211 Brief 99202
Expanded99212 Limited 99203 Detailed99213 Expanded 99204
Comprehensive99214 DetailedICD (P) 99205 Complex99215 Comprehensive
25 MODIFIER Separate E/M by same provider/same day NURSE ICD (S)
W9201 BriefW9211 Brief W9202 ExpandedW9212 Limited W9203
DetailedW9213 Expanded REF/DISP W9204 ComprehensiveW9214 Detailed
W9205 ComplexW9215 Comprehensive
Slide 54
Example of when to use the 25 Modifier: (Clinic) 39 year old
established pt comes in for Family Planning preventive visit, while
doing this pts family planning preventive visit, the APRN finds
vaginal warts, and with the permission of the pt, treats. Coding
would consist of: 99395 9921325 54
Slide 55
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
Slide 56
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
Slide 57
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
Slide 58
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
Slide 59
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
Slide 60
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.
Slide 61
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
Slide 62
NDC
Slide 63
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 00009-0746-30 Support Staff
enters F00009074630 in override