OEM How to Get the Workload Credit You Deserve

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OEM - How to Get the Workload Credit You Deserve!
NMCPHC Coding Brief

• Angela N. Andersen, CPC
• Lead Coder
• Naval Medical Center Portsmouth
• March 2009

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Course Overview

• Provide an overview of standard DoD and CMS
  coding guidelines.
• State the difference between ICD-9, EM and
  CPT/HCPCS codes.
• State the criteria for classifying a patient as
  New or Established and how to document
  accordingly
• Explain the required coding link between CPT
  (procedure) codes and ICD-9 codes.

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Contents

• Why Code?
• How do Codes equate to Workload Credit?
• Why is Documentation important?
• What documentation should be included on every
  encounter?
• Determining the correct EM code
• Time as the determining factor for EM code
  selection
• Preventive Medicine EM code requirements
• ICD-9 Code Categories and Guidelines

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Why Code?

• Why is it important to code in the military?
• REIMBURSEMENT
• Third Party Payers/Inter-agencies
• Prospective Payment System (PPS)
• FITREP input
• Over coding Fraud
• Under coding Lost RVUs/Revenue

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Coding Workload Credit

• A Relative Value Unit (RVU) is assigned to most
  procedure codes, including EM.
• The more complex the service, the higher the RVU
  value assigned
• New Patient RVUs gt Established Patient RVUs
• Consult RVUs gt New patient RVUs
• Prev Med RVUs gt Established patient RVUs
• Under the PPS, RVU average 72.00

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Why is Documentation Important?

• The documentation must support the EM code you
  select.
• Your documentation must support the medical
  necessity of the services provided. The first
  step is to clearly document the reason for every
  visit the chief complaint.
• The use of Follow-up is insufficient
  documentation as it does not indicate medical
  necessity. It is acceptable to document
  Follow-up for _____.
• Remember The coding rule of thumb is If it
  isnt documented, it wasnt done!

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What do Coders look for?

• Every patient encounter should be legible and
  include
• Date of Encounter
• Reason for the visit (chief complaint)
• Appropriate history of present illness
• An exam when necessary or appropriate i.e. a new
  patient (consistency and problem pertinent)
• Review of lab, xray, other ancillary services
  when appropriate
• Assessment
• Plan of care/Treatment options
• Provider signature
• Taken Care of or required fields in AHLTA
  (CHCSII)
• Remember It is the Content, not the volume, of
  documentation that determines your EM code!

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Final EM Selection

• Determining your Level of Service
• PF Problem Focused SF Straightforward
• EPF Expanded Prob Focused L Low Complexity
• D Detailed M Moderate Complexity
• C Comprehensive H High Complexity

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Time as a Key Component

• If more than 50 of your time with a patient is
  spent counseling or coordinating care, time can
  be used in selecting the EM level.
• Document counseling topics/coordination of care.
• Prognosis, differential diagnoses, risks/benefits
  of treatment, compliance, discussion with another
  healthcare provider
• Document providers total face-to-face time plus
  time spent counseling or coordinating care for
  patient.
• Example 45 min visit/30min counseling
• Do not include resident/support staff time with
  patient.

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The Disposition Module
The Time Factor section is only used when gt50 of
your time is spent counseling or coordinating
care. AHLTA will calculate the code based on
time only when both boxes are checked
Total time counseling time must be documented
in AHLTA, either within this box or in your SOAP
note.
Additional documentation is needed in the
record (i.e. diagnosis comment section, comments
box above) to support a visit for counseling or
coordination of carethe record must clearly
indicate why counseling/coordination of care went
above and beyond what is typical for an
encounter. The actual time spent counseling must
also be documented.
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Preventive Medicine

• New Patient
• 99381-99387
• Established Patient
• 99391-99397
• Counseling
• 99401-99404 Individual
• 99411-99412 Group
• 99381-99397 are based on the age of the patient
• 99401-99412 are based on time spent counseling.

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Preventive Medicine

• 99381-99397
• This code series includes counseling /
  anticipatory guidance / risk factor reduction
  interventions which are provided at the time of
  the initial or periodic comprehensive preventive
  medicine examination. Comprehensive in this code
  series is NOT synonymous with the comprehensive
  examination required in 99201-99350.
• 99401-99412
• This code series cannot be coded on the same day
  as a preventive medicine examination visit. To
  code for these services the patient cannot have
  any symptoms or an established illness.

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E/M RVUS

• 99387 2.06
• 99394 1.36
• 99395 1.36
• 99396 1.53
• 99397 1.71
• 99358 2.10
• 99359 1.00
• 99401 0.48
• 99402 0.98
• 99403 1.46
• 99404 1.95
• 99411 0.15
• 99412 0.25

• 99201 0.45
• 99202 0.88
• 99203 1.34
• 99204 2.30
• 99205 3.00
• 99211 0.17
• 99212 0.45
• 99213 0.92
• 99214 1.42
• 99215 2.00
• 99384 1.53
• 99385 1.53
• 99386 1.88

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ICD-9 Code Categories

• ICD-9 codes are organized by categories of
  disease or conditions
• (001-139) Infectious and Parasitic Diseases
• (140-239) Neoplasms
• (240-279) Endocrine, Nutritional, Metabolic
  Immunity Disorders
• (280-289) Diseases of the Blood and
  Blood-Forming Organs
• (290-319) Mental Disorders
• (320-389) Diseases of the Nervous System and
  Sense Organs
• (390-459) Diseases of the Circulatory System
• (460-519) Diseases of the Respiratory System
• (520-579) Diseases of the Digestive System
• (580-629) Diseases of the Genitourinary System
• (630-677) Complications of Pregnancy,
  Childbirth, and the Puerperium
• (680-709) Diseases of the Skin and Subcutaneous
  Tissue
• (710-739) Musculoskeletal System and Connective
  Tissue Diseases
• (740-759) Congenital Anomalies
• (760-779) Certain Conditions Originating in the
  Perinatal Period
• (780-799) Symptoms, Signs, and Ill-Defined
  Conditions
• (800-999) Injury and Poisoning
• V01-V82 V Codes - Factors Influencing Health
  Status and Contact With Health Service

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ICD-9 Guidelines

• General Guidelines
• Code to the highest degree of specificity. Carry
  the code to the fourth or fifth digit when
  possible.
• ALL CODING MUST BE SUPPORTED BY THE DOCUMENTATION
  IN THE MEDICAL RECORD.

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ICD-9 Coding Practices

• General guidelines
• Code the primary diagnosis first, followed by the
  secondary, tertiary, etc. diagnosis. The primary
  diagnosis is the main reason the Chief
  Complaint for the patient visit.
• Code coexisting conditions that affect the
  patients treatment in that visit. Code chronic
  conditions ONLY when they apply to the patients
  treatment. Dont code diagnoses that are no
  longer being treated or that dont affect your
  care of the patient.

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ICD-9 Coding Practices

• General Guidelines
• Rule out, suspected, and probable diagnoses
  cannot be coded. Assign the applicable code for
  the sign or symptom that is the reason for the
  patient visit.
• Use ICD-9 codes 780 through 799 (Signs
  Symptoms) to describe symptoms, signs, and ill
  defined conditions that arent linked to a
  specific conditions.

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ICD-9 Coding Practices

• General Guidelines
• ICD-9 V codes are used to identify
  circumstances (diagnoses) other than disease or
  injury that are the reason for an encounter with
  a physician or other provider.
• The V codes are used to document an encounter and
  classify a patient who is not currently or
  acutely ill, but who requires health care
  services.

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ICD-9 Coding Practices

• General Guidelines
• Enter an E-Code to support External Cause of
  Injury or Poisoning (including Adverse Drug
  Reactions).
• An ICD diagnosis code between 800 through 999
  should have a valid E-Code.
• An "E" code should NOT be entered as the
  principal diagnosis.
• Guideline change Historically DoD has required
  that all encounters for accidents/injuries
  related to wartime have the E code on every
  encounter. This guideline was changed in 2009,
  now E codes are only to be used on the first
  encounter for all accident/injuries.

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CPT Codes

• Current Procedural Terminology (CPT) is a
  proprietary code set developed by the American
  Medical Association (AMA) to identify procedures
  and services performed by physicians.
• Each procedure and service is associated with a
  5-character numeric code.
• CPT Codes are also referred to as HCPCS Level I
  Codes.

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CPT Codes

• HCPCS Level II codes are a collection of
  approximately 3200 additional codes, that
  identify medical and surgical supplies, certain
  drugs, durable medical equipment, and services
  generally provided by non-physicians.
• HCPCS Level II codes are 5-character codes that
  start with a letter indicating a class of codes
  and then contain four numeric digits.

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Coding for Clinic Procedures

• The only procedures that should be entered into
  ADM are those procedures that are completely
  performed within the clinic.
• Laboratory or Radiological procedure codes should
  NOT be entered into ADM if they are performed in
  the Ancillary work center areas.

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Capture More Workload

• Smoking Cessation Counseling
• 99406 3-10 minutes
• 99407 10 minutes
• Digital Rectal Exam for Prostate Cancer Screening
• G0102
• Visual Acuity Exam (Snellen Chart)
• 99173
• Needle Sticks!!
• 96150 when the OH nurse sees a patient due to
  a needle stick he/she can code this encounter as
  99499 E/M and 96150 CPT with the applicable ICD-9
  primary for the wound and a secondary ICD-9 code
  of the External cause.

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Common Coding Errors in OEM

• V68.0x Issuance of Certificate
• This is a PRIMARY only ICD-9 code and should not
  be used in the secondary diagnosis slot.
• V70.x General Medical Exam
• This is a PRIMARY only ICD-9 code and should not
  be used in the secondary diagnosis slot.
• Routine visits that turn into an Acute visit for
  a finding upon exam.
• Providers must document all applicable
  information required for the preventive service.
• If an acute finding is discovered and managed
  during the same encounter the provider should
  Expand his/her documentation pertinent to this
  finding and code an ADDITIONAL separate E/M code
  for the acute finding.

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Common Coding Errors in OEM

• Coding in AHLTA
• You MUST verify the E/M code chosen by AHLTA in
  the Disposition screen.
• It has been a common place error that providers
  are being given non-count E/M code 99429 for
  preventive visits OR Preventive E/M 99381-99397
  for acute care visits.
• New patient vs. Established patient
• While the front desk books these appointments
  providers should always double check the patients
  status in AHLTA.
• New patients are worth higher RVUs and you will
  lose out if you let the system default to an
  established patient E/M.
• Preventive Medicine and Acute Care Same Day
• AHLTA will not automatically code your encounter
  with a Preventive E/M (99381-99397) and an Acute
  E/M (99201-99215).
• The provider must manually code the additional
  E/M code in the disposition screen based on
  his/her documentation. Be sure to add a 25
  modifier to your Acute E/M.

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PROCEDURAL RVUS

• 94010 0.17
• 99000 0.05
• 36415 0.06
• 96150 0.50
• 96151 0.48

• 99173 0.00
• 93000 0.17
• 93010 0.17
• G0102 0.17

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T-Con Code Changes

• Old T-Con Codes
• Codes 99371, 99372 and 99373 will be deleted from
  systems (CHCS, AHLTA) when AHLTA 3.3 is loaded
• Expected date of implementation end of March
• New T-Con Codes
• Rules for use more strict than the old codes
• Call must be initiated by the patient
• Four new EM codes for privileged providers
• Four new CPT codes for non-privileged providers

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DoD Coding Rules for T-Cons

• New T-Con codes are time-based document your
  time when coding for the service.
• DO NOT ASSIGN TELEPHONE SERVICES CODES FOR
• Provider initiated phone calls
• Telephone services referring to an EM service
  performed and reported by the same provider
  occurring within the past 7 days
• Telephone services ending with a decision to see
  the patient within 24 hours or next available
  urgent visit appointment
• Telephone services occurring within the post
  operative period of the previously completed
  procedure
• New patient interaction
• Provider to provider interaction
• Provider to commander interaction
• Leaving messages on answering machines
• Scheduling/Billing/Administrative issues
• Communication of non-clinical information
• Telephone services completed by residents that
  are PGY-1s
• Any other administrative issues
• Providing test results

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Documenting T-Cons not Coded

• Documentation is important for all T-cons. There
  are two options available for documenting a T-con
  that doesnt qualify for coding under the new
  guidelines
• Can be used for privileged and non-privileged
  provider-initiated telephone calls.
• Use the T-con module to document the call and
  code the service with 99499, or
• If the call is related to an appointment that
  occurred within the past 7-days, open the
  patients previous appointment, click Append
  Narrative, document the phone call, then sign.
  The documentation will appear at the end of the
  encounter as an added note.

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New T-Con Codes for Privileged Providers
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Privileged Provider T-Cons
Display of the new 2008 EM Telephone Consults
codes in the Drop Down tab of Disposition module.
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New T-Con Codes for Non- Privileged Providers
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Non-Privileged Provider T-Cons
The new non-physician codes are CPT codes and are
located in the Procedure tab in the A/P module.
The new non-physician codes can also be put into
a new or existing template and used for Telephone
Consults.
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These new CPT codes have been Made into a
template that can be found In the MTF folder
under Portsmouth
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Non-Privileged Provider T-Cons
99499 is the only EM code available for
non-privileged providers with the needs
supervising signature set to yes in CHCS seen
here in the Selection tab in Disposition.
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Summary

• Are you going to let RVUs slip away?
• By incorporating some of the information
  discussed today into your notes, you can honestly
  increase your RVUs and reimbursement.
• Keep in mind that AHLTA does not code for you
  completely you must always check your codes
  before finalizing your note.
• Templates are your best tool to maximize your
  coding in AHLTA.

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Internet Resources

• TMA
• http//www.tricare.mil/tma/default.aspx
• ICD-9 Code Categories and Code Look-up -Tabular
  and Alphabetical list
• http//www.mcis.duke.edu/standards/termcode/icd9/1
  tabular.html
• What Is Our Coded Data Telling Us?
• http//www.lenoxpublishing.com/ce-coded.htm
• Developing a Coding Compliance Document
• http//www.ahima.org/journal/pb/01.07.1.html
• Guidelines for Coding Reporting
• http//www.eicd.com/Guidelines/Default.htm
• DoD Coding Guidelines
• http//www.tricare.mil/ocfo/bea/ubu/coding_guideli
  nes.cfm

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Questions?

• Contact Information
• Angela N. Andersen, CPC
• Office 757.953.1241
• Mobile [phone]
• Fax [phone]
• Email Angela.Andersen_at_med.navy.mil