Billing and Coding Alison Mancuso, DO

25 Pages·2016·0.91 MB·English

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Billing and Coding
Alison Mancuso, DO

3/17/2016
Alison Mancuso DO
Assistant Professor & Residency Program Director
Department of Family Medicine
Rowan School of Osteopathic Medicine
© Alison Mancuso DO
Overview
CPT Coding
Preventative Service Coding
Medicare Wellness Coding
Evaluation/Management Coding
OMT Billing
Modifiers
Additional Billable Services
Proper Billing of Immunizations
© Alison Mancuso DO
Learning Objectives
At the conclusion of this presentation, the participants
should be able to:
 1. Differentiate between a 99213 and a 99214 level
service.
 2. Identify where a -25 Modifier is necessary for
proper reimbursement
 3. Identify proper preventive service codes for
Medicare Preventative Services
 4. Identify which counseling services may be
reimbursable in the office setting
 5. Identify proper billing codes for immunizations
based on age & insurance coverage
 6. Identify proper billing strategies for OMT
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© Alison Mancuso DO
Definition: CPT
 Stands for Current Procedural
Terminology
 A list of descriptive terms and identifying
codes for reporting medical services and
procedures
 Provides a uniform language
Describes medical, surgical, diagnostic services
Reliable nationwide communication
 Providers, Facilities, Third-Parties (Insurers, etc)
 Main Types in FM
E/M
Preventative
Procedures
© Alison Mancuso DO
HCPCS
Healthcare Common Procedure Coding
System
“hicks picks”
Developed by CMS
Describe many different parts of
healthcare
Level 1: CPT Codes
Level 2: Devices and Supplies
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© Alison Mancuso DO
CPT Codes-Preventative Care
“Health Maintenance”, “Physical”, “Well-
Visit”
Based on Age and New/Established
Status
Note: MEDICARE does not cover these
codes
Separate HCPCS Codes for this
© Alison Mancuso DO
CPT: Preventative Services
New Patients Established Patients
 99381: <12 months  99391: <12 months
 99382: 1-4yrs  99392: 1-4yrs
 99383: 5-11yrs  99393: 5-11yrs
 99384: 12-17 yrs  99394: 12-17 yrs
 99385: 18-39 yrs  99395: 18-39 yrs
 99386: 40-64 yrs  99396: 40-64 yrs
 99387: 65+ years*  99397: 65+ years*
* MEDICARE does not reimburse for this
service © Alison Mancuso DO
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Medicare Wellness
Medicare has separate Preventative
Service HCPCS codes (similar to a
CPT)
New with Affordable Care Act in 2011
Coverage of certain preventative services
○Annual Wellness Visit
○USPSTF Grade A/B Recommendations
○ACIP Recommendations
Some in Medicare Part B, Some in Medicare Part D
© Alison Mancuso DO
Medicare Wellness
HCPCS Codes
G0402: Initial Preventative Physical Exam
G0438: Initial Annual Wellness Visit
G0439: Subsequent Annual Wellness Visit
Differences in timing of visit and how
long the patient has been with Medicare
© Alison Mancuso DO
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CPT Codes for E/M Services
Evaluation and Management services (“Office
Visits”)
Based on Complexity of: History/Exam/Medical Decision Making
New Patient Visits-Problem Based
99201
99202
99203
99204
99205
Established Patient Visits-Problem
Based
99211* No physician necessary
99212
99213
99214
99215
© Alison Mancuso DO
CPT: Hospital Visits
Based on Complexity of History/Exam/Medical Decision
Making
Initial Hospital Visit
 99221
99222
99223
Hospital Follow Up
 99231
99232
99233
© Alison Mancuso DO
CPT- Hospital: Observation
99234
99235
99236
Again, based on Hx, Exam, MDM
Note:Patients are not admitted to the hospital
they are on Observation Status
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Picking the Correct Code
 Divided into 3 Key Components of
Evaluation/Management (E/M)
 History
 Examination
 Medical Decision Making
 Counseling & Coordination of Care
 Time
 Time can trump the others, but it must be well
documented. Total time and the time spent in counseling
and coordination of care must be documented
 Office Visit: MUST be face-to-face
 Hospital: Can include floor time
© Alison Mancuso DO
E/MComponent: History
Level of Service Based On:
HPI
Review of Systems
Past Medical/Family/Social History
© Alison Mancuso DO
History Components
Component Prob ExpProb Detailed Comprehen
Focused Focus sive
HPI- 1-2 Chronic 3 Chronic
Chronic Conditions Conditions
Conditions (Status) (Status)
HPI-Acute* Brief (1-3 Extended (4+
elements) elements)
ROS None Pertinent 1 Extended Complete
System (2-9 (10+
systems) systems)
PFSH None Pertinent(1 Complete (2
area) or 3 areas)
• HPI Acute Elements: Location, Quality, Severity, Duration, Timing, Context,
Modifying Factors, Associated Signs/Symptoms
New Patient: Level Determined by 3 out of 3 components(lowest common)
Established Patient: Level Determined by 2 out of 3 components (lowest
common) © Alison Mancuso DO
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History Components: Example
Component Prob ExpProb Detailed Comprehens
Focused Focus ive
HPI-Chronic 1-2 Chronic 3 Chronic
Conditions Conditions Conditions
(Status) (Status)
HPI-Acute* Brief (1-3 Extended (4+
elements) elements)
ROS None Pertinent 1 Extended Complete
System (2-9 (10+
systems) systems)
PFSH None Pertinent(1 Complete (2
area) or 3 areas)
• HPI Acute Elements: Location, Quality, Severity, Duration, Timing, Context,
Modifying Factors, Associated Signs/Symptoms
New Patient: Level Determined by 3 out of 3 components(lowest common)
Established Patient: Level Determined by 2 out of 3 components (lowest common)
© Alison Mancuso DO
History Components: Example
NEW PT
LEVEL EST PT LEVEL
Component Prob ExpProb Detailed Comprehens
Focused Focus ive
HPI-Chronic 1-2 Chronic 3 Chronic
Conditions Conditions Conditions
(Status) (Status)
HPI-Acute* Brief (1-3 Extended (4+
elements) elements)
ROS None Pertinent 1 Extended Complete
System (2-9 (10+
systems) systems)
PFSH None Pertinent(1 Complete (2
area) or 3 areas)
• HPI Acute Elements: Location, Quality, Severity, Duration, Timing, Context,
Modifying Factors, Associated Signs/Symptoms
New Patient: Level Determined by 3 out of 3 components(lowest common)
Established Patient: Level Determined by 2 out of 3 components (lowest common)
© Alison Mancuso DO
E/M Component: Exam
 Exam Criteria based on Body areas OR
Organ Systems (not combination)
 4 elements in each area/system
 Body Areas
Head/Face; Chest/Breast/Axillae; Abdomen;
Neck; Back/Spine; Genitalia/Groin/Buttocks;
Each Extremity
 Organ Systems
Constitutional (vitals/appearance); Eyes;
Ears/Nose/Mouth/Throat; Cardio; Respiratory;
GI; GU; Musculoskeletal; Skin; Neuro: Psych;
Heme/Lymph/Immu
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Exam Components
Prob ExpProb Detailed Comprehensi
Focused Focus ve
Body 1 Up to 7 Up to 7 8+(General
Area/System area/system systems systems multisystem
(affected) (affected (affected exam or
+symptomati and in complete
c or related) depth exam of single
related) organ system)
4 elements in each Body Area examined should be examined &
documented
Example: Cardio: regular rate, +s1/+s2, no murmurs, non-
displaced PMI
© Alison Mancuso DO
E/M Component: Medical Decision Making
Complexity of Diagnosis and Management
Three Elements:
Number of possible diagnoses and/or number
of management options (Box A)
Amountand/or complexity of medical
records, diagnostic tests, and /or other
information that must be obtained (Box B)
Risk of complications, morbidity, and/or
mortality as well as co-morbidities assoc. with
problems, diagnostic procedures, and the
possible management options (Box C)
© Alison Mancuso DO
Medical Decision Making Components
BOX A: Number of Diagnosesor Treatment Options
ProblemStatus Number Points Result(NxP)
Self- Max =2 1
Limited/Minor
Est Problem (to 1
examiner)
/Stable,
Improved
Est Problem, 2
Worsened
NewProblem Max = 1 3
(to examiner);
no additional
w/u
New Prob; 4
additional w/u
TOTAL
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