Doing It Right The First Time

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Doing It Right The First Time

• Steven A. Adams, CPC, CPC-H, COA

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What You Want...
3
What You Get...
4
Remember
5
Remember
- Embrace Optimism -
6
Remember
- Embrace Optimism -
7
Discussion Points

• 2006 Payment Update
• E and M Coding for
• Consultations
• Outpatient
• Inpatient
• Observation
• Nursing Home
• Modifiers Global Surgery Rules
• New Injection Codes for 2006
• New Laboratory Codes for 2006
• Break
• Preventive Services - Part 2

8
2006 Medicare Payment Update
One of the most valuable things we can do to heal
one another is listen to each other's
stories. Rebecca Falls
9
2006 Payment Update
The Centers for Medicare Medicaid Services
(CMS) expects to pay approximately 57.6 billion
to 875,000 physicians and other health care
professionals in 2006, according to a final rule
released today that will update payment rates and
revise payment policies under the Medicare
Physician Fee Schedule. The final rule expands
Medicare coverage of glaucoma screening expands
access for rural beneficiaries enrolled in
Medicare Advantage plans to services of federally
qualified health centers (FQHCs) adopts a
modified approach to reforming payment for
multiple imaging procedures performed on a
beneficiary at one session and revises payment
for inhalation therapy and end stage renal
disease (ESRD) treatment. The physician fee
schedule specifies payment rates to physicians
and other providers for more than 7,000 health
care services and procedures, ranging from simple
office visits to complex surgery. The fee
schedule is updated on an annual basis according
to a formula specified by statute that takes into
account the rate of growth in overall Medicare
spending for physicians services in recent
years. The final rule indicates that, based on
the update formula, payment rates per service for
physicians services will be reduced by 4.4
percent for 2006.
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EM Coding Update
Always be nice to your children because they are
the ones who will choose your nursing
home. Phyllis Diller
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Outpatient Visit
New / Consults 99201 - 99245 Requires All Three
Key Elements
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1
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Medicare Transmittal 1644

• Consultation Versus Visit - Pay for a
  consultation when criteria is met
• opinion is requested by another physician
• need for consultation is documented in note
• written report is provided to referring physician

Payment may be made regardless of treatment
initiation unless a transfer of care occurs. A
transfer of care occurs when the referring
physician transfers the responsibility for the
patients complete care at the time of the
referral.
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Medicare Transmittal 1644

• Consultation for Preoperative Clearance - Pay for
  the appropriate consultation code for a
  pre-operative consultation for a new or
  established patient performed by any physician at
  the request of a surgeon, as long as all of the
  requirements for billing the consultation codes
  are met.

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Distribution Studies

• Download the graph
• Pull the notes that correspond to the most common
  code(s) picked by you or your doctor
• Use the forms to audit those notes
• Offer constructive suggestions

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(No Transcript)
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Just Do It

• New Patients / Consults
• Get a Comprehensive History
• Do Comprehensive Exam
• Select Code Based Upon MDM

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History

• 1. Problem Focused
• 2. Expanded Problem Focused
• 3. Detailed
• 4. Comprehensive

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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
21
History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
22
History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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1995 Exam

• 1. Problem Focused
• 2. Expanded Problem Focused
• 3. Detailed
• 4. Comprehensive

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1995 Examination Component
The following are recognized organ system by AMA
and CMS. There are 14 on the list, you can only
examine 12

• Constitutional
• Eyes
• Ears/Nose/Mouth/Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary

• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Hematologic/Lymphatic
• Allergic/Immunologic
• Endocrine

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1995 Examination Component

• Comprehensive
• 8 System Exam

Const Well Developed Eyes PERRLA CV RRR Lungs
CTA
Abd Bowel Sounds Skin Warm, Dry Neuro
Intact Psych A O X 3
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Medical Decision Making

• 1. Straightforward
• 2. Low Complexity
• 3. Moderate Complexity
• 4. High Complexity

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Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
6
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Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
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Codes
Decision Making
Exam
History
Code
Minimal
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Codes
62 95
Decision Making
Exam
History
Code
Minimal
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Low
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
33
Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
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Codes
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Codes
92 127
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
37
Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Rx
Stress Tests
Undiagnosed
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
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Codes
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Codes
130 170
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
40
Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
41
Table of Risk
Management Options
Diagnostic Procedures
Presenting Problems
Level
Rest
Chest X-Ray
Minimum
Self-limiting
Pulmonary Function
OTC
Low
Uncomplicated
Moderate
Stress Tests
Undiagnosed
Rx
Endoscopy w/risk
Major Surgery w/risk
Threat to Life
High
42
Codes
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
43
Codes
165 213
Decision Making
Exam
History
Code
Straightforward
99202
Exp. Problem Focused
Exp. Problem Focused
Low
Detailed
99203
Detailed
99204
Comprehensive
Comprehensive
Moderate
Comprehensive
Comprehensive
99205
High
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Outpatient Visit
Established Patient 99211 - 99215 Requires Two
of Three Key Elements
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1
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Just Do It

• Established Patients
• Get a Detailed History - Nurses
• Dont Worry About Examination
• Select Code Based Upon MDM

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Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
Prescription Refill / Medication Counseling
Nurse Note Talked to patient to ensure meds
were working. Gave refills for one week and
scheduled f/u visit
1) 2) 3)
HTN
99211 - 19
49
Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
F/u Congestion - resolved
Chest 3 Weeks Resolved No more complaints
? See NPI form, reviewed and updated
? See NPI form, reviewed and updated
1) 2) 3)
Bronchitis - resolved - d/c Advair
99212 - 36
50
Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
Congestion
Chest 3 Weeks Burns when coughing Worse in morning
? See NPI form, reviewed and updated
? See NPI form, reviewed and updated
1) 2) 3)
Bronchitis - unstable - Advair
99213 - 49
51
Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
F/u HTN, DM
HTN - No c/o DM - Sugars OK
? See NPI form, reviewed and updated
? See NPI form, reviewed and updated
1) 2) 3)
HTN - stable
99213 - 49
DM - stable
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Established Patient
Complaint ? Status of 3 Conditions Location Dur
ation Severity Timing ROS M,F,S Hx
F/u HTN, DM, Arthritis
HTN - No c/o DM - Sugars OK Arthritis - Shoulder
Not Hurting
? See NPI form, reviewed and updated
? See NPI form, reviewed and updated
1) 2) 3)
HTN - stable
99214 - 78
DM - stable
Arthritis - stable
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Established Patient
Complaint ? Status of 3 Conditions Location Dur
ation Severity Timing ROS M,F,S Hx
F/u HTN, DM, Arthritis
HTN - Pressures Up DM - Sugars OK Arthritis -
Shoulder Hurting Again
? See NPI form, reviewed and updated
? See NPI form, reviewed and updated
1) 2) 3)
HTN - unstable
99214 - 78
DM - stable
Arthritis - unstable
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Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
Discussion of abnormal lab tests
1. 25 minutes face-to-face 2. gt 50
counseling 3. Topics Discussed Weight Loss,
diet and exercise
1) 2) 3)
Abnormal weight gain
99214 - 78
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Established Patient
Complaint Status of 3 Conditions Location Durat
ion Severity Timing ROS M,F,S Hx
Discussion of new dx of colon cancer
1. 40 minutes face-to-face 2. gt 50
counseling 3. Topics Discussed surgical
options discussed
1) 2) 3)
Colon cancer
99215 - 115
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Inpatient, Observation, Nursing Home, etc.
If you want something said, ask a man if you
want something done, ask a woman. Margaret
Thatcher
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See Forms To Remember The Correct Codes
99221 - 66 99222 - 110 99223 - 152 99231 -
33 99232 - 54 99233 - 77 99238 - 68 99239 -
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2,13
58
Hospitals Work on Calendar Days not HOURS - See
Form For Correct Coding
99234 - 131 99235 - 173 99236 - 216 99218 -
65 99219 - 108 99220 - 152 99217 - 68
3
59
Major Code Changes for 2006! - See Form For
Proper Coding
99301 - 64 99302 - 85 99303 - 105 99311 -
32 99312 - 54 99313 - 77
4,15
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CPT Modifiers
Fear is a disease that eats away at logic and
makes man inhuman. --Marian Anderson
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Not In Global Package

• Initial Consult
• Unrelated Visits
• Diagnostic Test
• Return Trips to OR
• Staged Procedures

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EM MODIFIERS ONLY 21 24 25 32 52 57
22
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Minor Surgery / Service

• 22 - Surgery Only
• 24 - EM Only
• 25 - EM Only (Minor surgery / service)
• 26 - Professional Component
• 57 - EM Only (Major surgery)
• 58 - Surgery Only (Related, staged)
• 78 - Surgery Only (Related, complication)
• 79 - Surgery Only (Not Related)

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Medicare Covered Service You Probably Dont Code
Government, even in its best state, is but a
necessary evil in its worst state, an
intolerable one. Thomas Paine
65

• Initial Preventive Physical Exam
• EKG
• Pelvic examination
• Pap - obtain
• Occult Blood
• Flu vaccine
• Pneumonia vaccine
• Hepatitis vaccine
• Colonoscopy patient at high risk
• Colonoscopy screening exam
• Prostate exam
• DM self-management
• Bone Mass Measurement (DEXA)
• Mammogram
• Smoking Cessation 3-10 minutes
• Smoking Cessation gt 10 minutes
• Cardiovascular screening
• Diabetes screening

• G0344 100.84
• G0366 28.35
• G0101 39.09
• Q0091 42.14
• G0107 4.49
• G0008 18.66
• G0009 8.66
• G0010 8.66
• G0105 401.85
• G0121 401.85
• G0102 22.37
• G0108 34.18
• 76075 147.89
• 76092 89.93
• G0375 13.20
• G0376 26.03
• 80061 18.72
• 82947 5.48

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Medicare Information
G0101 - 39.09

• G0101 - Breast and pelvic
• Q0091 - Pap smear
• G0107 - Occult Blood
• V76.51 CA screen of colon
• V76.2 CA screen of Cervix
• V76.47 CA screen of Vagina
• V76.49 Woman without Cervix
• V15.89 High risk Cervical CA

Q0091 - 42.14
G0107 - 4.49
67
Medicare Information

• G0179 - Home Health Recertification - 70
• G0180 - Home Health Certification - 80
• G0181 Home Health Agency gt30 Min - 115
• G0182 Hospice Care gt30 Minutes - 125

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Smoking Cessation
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New Injection Codes
When will our consciences grow so tender that we
will act to prevent human misery rather than
avenge it? Eleanor Roosevelt
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Effective 1/1/05 Medicare No Longer Accepts
90782
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Medicare Injection Codes
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New Medicare Injection Reimbursement
Indicates an additional payment for
anti-neoplastic drug use
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Vaccines
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New Injection Codes 2006

• 90780 - Infusion
• 90781 - each hour
• 90782 - Therapeutic
• 90788 - Antibiotic

• 90760 - IV Hydration
• 90761 - each hour
• 90765 - IV Therapy
• 90766 - each hour
• 90772 - IM Injection
• 90772 - IM Injection

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New Laboratory Codes

• To be successful, a woman has to be much better
  at her job than a man.
• Golda Meir

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Common Code Changes

• Occult Blood (guaiac)
• ? 82270 - 3 cards/triple card
• 82271 - other sources
• 82272 - single specimen

• Hemoglobin
• ? 83036 - A1C
• 83037 - A1C by FDA device

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Common Code Changes

• Occult Blood (guaiac)
• ? 82270 - 3 cards/triple card
• 82271 - other sources
• 82272 - single specimen

• Hemoglobin
• ? 83036 - A1C
• 83037 - A1C by FDA device

78
Discussion Points

• 2006 Payment Update
• E and M Coding for
• Consultations
• Outpatient
• Inpatient
• Observation
• Nursing Home
• Modifiers Global Surgery Rules
• New Injection Codes for 2006
• New Laboratory Codes for 2006
• Break
• Preventive Services - Part 2

79
How Do I Remember All This Stuff?
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You Cant
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Library

• Coders Desk Reference
• Principles of CPT/ICD-9
• CPT Changes
• Coding Alert Magazines
• Coders Edge - AAPC

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Resources

• cms.gov
• gamedicare.com/provider/EandM/index.htm
• oig.hhs.gov/publications/workplan.html
• cms.hhs.gov/providerupdate/whatsnew.asp
• cms.hhs.gov/physicians/cciedits/default.asp
• medville.com
• aapc.com

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Remember
If all else fails, destroy the evidence, find a
new job, and blame your failures on someone
else. Steven Adams
84

• Questions
• Evaluations