Coding 101
Taken from “Beginning Coding”, “Intermediate
Coding”, and “I Hate Coding” by Dianne Demers
Ice Breaker
2
Coding and Documentation

Objectives:
The Participant will be able to
● Define CPT, ICD 9, and DSM 4 Coding
● Explain the reasons why appropriate coding
and documentation is so important in SBHC
settings.
● Demonstrate correct use of CPT and ICD 9
codes
3
Coding Background and
Terminology
4
Coding Definition

Coding is an alphanumeric system used to
translate medical procedures and services
into data
5
Types of Coding



Current Procedural Terminology (CPT)
International Classification of Diseases
(ICD-9 Clinical Modification - CM)
Diagnostic and Statistical Manual of Mental
Disorders (DSM IV-TR)
6
Coding Is Not The
Same As Billing
7
Coding is Medicare Drive

Pediatrics was not considered in
original coding guidelines, so some of
the things we do in SBHCs may not fit
well
8
SBHC Coding

There is no difference between coding
in a SBHC and any other setting – the
coding assumptions are the same.

You provide the same level of care
regardless of the location.
9
Why Code Correctly?
● Reimbursement depends on it.
● Codes describe the services you
provide
● Codes justify these services
● Services not documented “never
happened”
PS: Never code for the purpose of
getting more money
10
The Coding Process has 2 Parts
1. “What you did” = CPT
2. “Why you did it” = ICD-9 or DSM-4 TR
YOU MUST ALWAYS USE BOTH
a what and a why
(NO EXCEPTIONS)
11
When a provider is undercoding they tell the wrong story
This wrong story is:
 SBHC Providers are seeing very few
patients with multiple problems.
 SBHC Providers should see more
patients since they are not seeing
complicated patients.
 The SBHC should decrease the
number of physicians and add more
mid-level providers.
12
There Are Two Coding
Guidelines - 1995 & 1997
Both 1995 and 1997 guidelines are
approved for use by CMS
 Agencies may specify use of 1995 or
1997 guidelines
 1997 guidelines are more specific than
1995 in the examination portion (they
are more computer friendly)
 New guidelines have been proposed,
but have not yet been accepted

13
Coding Guidelines
1995 vs. 1997
This lecture is based on the 1995
guidelines because they are 15 pages
long vs. 57 pages of the 1997 version.
www.cms.hhs.gov/MLNProducts/Download
s/1995dg.pdf
14
Fraud

Intentional deception or
misrepresentation
● Deliberately billing for services not
performed
● Unbundling of services
● Intentionally submitting duplicate claims
15
Abuse

Improper billing practices
● Billing for non-covered services
● Misusing codes on a claim form
16
Errors


Accept it, you will
make them.
Your best defense
is having a plan for
your coding and
being able to
explain it.
17
Coding Does Not
Equal Good
Medicine
18
But - Coding is Good
Documentation
19
CPT Codes document:

Level of Service

Procedures Provided
20
Examples of CPT codes
Evaluation
&
Management
99211
99212
99213
99214
99215
Preventive
Health
99391
99392
99393
99394
99395
99397
99397
21
ICD-9 Codes document:
The reason behind the visit
(They must support the CPT codes)
22
General Coding Principles
Coding gets you paid for your services
 Coding can be used to justify the need
for services to your funders

23
Coding with ICD-9

ICD-9 codes have 3, 4 or 5 digits
● The greater the number of digits, the
higher the specificity
● Use a 5-digit code when it exists
● Use a 4-digit code only if there is no 5digit code with the same category
● Use a 3-digit code only if there is no 4digit code within the same category
PS: Omitting the required 4th or 5th digit will
result in the denial of a claim. Do not add any
additional digits, even zero
24
ICD-9-CM Codes
Range from 001.0 to V82.9
 They identify:
● Diagnoses
● Symptoms
● Conditions
● Problems
● Complaints
● Other reason for the procedure, service, or
supply provided
25
ICD-9-CM Codes

Three volumes
● Volume 1 Tabular List of Diseases
● Notes all exclusive terms and 5th-digit
instructions
● Volume 2 Alphabetic Index of Diseases
● Does not contain detail – Do Not code
from this volume
● Volume 3 Procedures
● Used almost exclusively for hospital
services
PS: (All 3 Volumes are generally found in one binding)
26
“V” Codes


For circumstances other than disease or injury
Three categories:
● Problem – Could affect overall health
status, but is not a current illness or injury
● Ex.: V14.2 Personal history of allergy to
sulfonamines
● Service – Circumstances other than illness
or injury
● Ex.: V68.1 Issue of a repeat prescription
● Factual – Certain facts that do not fall into
the “problem” or “service” categories
27
“V” Codes

Can be used as a:
● Solo Code
● Principal code
● Secondary code

May represent check-ups, screenings,
administrative requests, prescription
refills
28
Rules for Coding
Outpatient Visits
29
Determine Type of Office Visit

Evaluation and Management
New Patients vs. Established Patients

Preventive Health Visits
New Patients vs. Established Patients

Counseling Visits
Medical Visit – talker only

Mental Health Visits
New Patients vs. Established Patients
30
Determine Medical Necessity
Services are reasonable and
necessary for the diagnosis and
treatment of illness or injury.
 All payors define necessity differently
 Clinical rationale must be documented
through coding.
 You cannot write more, to get paid
more.

31
Determine Chief Complaint

The reason for the patient’s visit
● S of a SOAP note
Codes used must relate to chief
complaint or they are invalid
 And, the chief complaint must be
documented in the chart

32
Evaluation/Management
(E / M) Services
Used for acute care visits
 Five levels of service
 Seven components within the levels

● Key components – history, exam and
medical decision making
● Contributory components – counseling,
coordination of care, nature of presenting
problem, and time
33
Evaluation/Management
(E / M) Services

Beginning information about coding
deals with the three key components:
● History
● Examination
● Medical Decision Making
34
Evaluation/Management
(E / M) Services
There are 5 Levels of service
1. Minimal
2. Self-Limited or Minor
3. Low Severity
4. Moderate Severity
5. High Severity
35
CPT Codes Used for E/M Visits
New Patients
Level 1
Level 2
Level 3
Level 4
Level 5
99201
99202
99203
99204
99205
Established Patients
99211
99212
99213
99214
99215
37
Coding Steps
38
Coding Steps

First Step - Determine if your patient is:
A New Patient
or
An Established Patient
39
Definition of a new patient:
It is the patient’s first visit to the provider
 The patient has not received any
professional services from the provider
or another provider of the same specialty
who belongs to the same group practice,
within the past three years.

PS: Any time a patient is seen in an
Emergency Room they are considered a
new patient
40
If your patient does not
meet the definition of a
New Patient,
then they are an
Established Patient
41
Coding Steps

Second Step - determine the level of
service for the visit,
To do this you need to determine the level of
service for each key component separately
There are 3 key components
They are:
1. History (HPI, ROS, PFSH)
2. Examination
3. Medical Decision Making
42
Coding Steps
New Patients
Within the 3 key components, there are
5 levels of service
 Remember to Consider the Key
Components separately:

● HPI, ROS, PFSH
● Examination
● Medical Decision Making
43
Example - New Patient
The Level of Service for a new patient visit is
determined by the lowest level of service (1
through 5) of the three key components
HPI, ROS, PFSH
4
Examination
4
3
Medical Decision Making This is the lowest level
44
Coding Steps
Established Patients

Again Consider the Key Components
Separately:
● HPI, ROS, PFSH
● Examination
● Medical Decision Making

The level of service (1 – 5) is
determined by the level that appears in
2 of the three components, or by the
middle level
45
Example – Established Patient
HPI, ROS, PFSH
3
This is the middle level
EXAM
2
Medical Decision Making
4
46
Why is this?
47
Answer . . .
There has to be a
system, and this is what
AMA came up with.
48
How to Steps of Coding
49
How to Steps of Coding:
Determine Level of Medical Decision Making
Determine Level of History Component
Determine Level of Physical Examination
(You will need to reference the chart – examination notes for this)
50
Determine Level of Medical
Decision Making

Medical Decision Making consists of
three sections:
● Diagnosis or Management Problems
● Diagnostic Procedures
● Treatment of Management Options

Level is determined by the level found
in two of the three categories – or the
middle number if all three are different
51
Determine Level of Medical Decision Making
Section I: Diagnosis or Management of Problems
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
One selflimited or
minor
problem
Two or more selflimited or minor
problems
One stable chronic
condition
Acute
uncomplicated
illness
One or more chronic
illnesses with
complications
Two or more stable
chronic conditions
Undiagnosed new
problem w/uncertain
prognoses
Acute illness with
systemic
symptoms
One or more chronic
illness with severe
complications
Acute or chronic
illness or injury that
is life or limb
threatening
Abrupt change in
neurologic status
Acute complicated
injury
52
Determine Level of Medical Decision Making
Section II: Diagnostic Procedures
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Lab
X-ray
EKG
UA
Ultrasound,
etc.
Venipuncture
KOH
Physiologic tests
not under stress
Pulmonary
Function
Barium Enema
Arterial puncture
Skin biopsies
Physiologic tests
under stresscardiac stress tests
Diagnostic
endoscopies with
no risk factors
Deep needle or
incisional biopsy
Obtained fluid from
body
Cardiovascular
imaging with
contrast
Cardiovascular
imaging with contrast
Invasive diagnostic
tests
Cardiac
Electrophysiological
tests Diagnostic
endoscopies with
identified risk factors
Discography
53
Determine Level of Medical Decision Making
Section III: Treatment or Management Options
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Rest
Gargles
Elastic
bandages
Dressings
OTCs
Minor surgery
PT
OT
IVs without
additives
Minor surgery with risk
factors
Elective major surgery—
no risk factors
Prescription drug
management
IV fluids with additives
Closed facture or
dislocation treatment w/o
manipulation
Therapeutic nuclear
medicine
Elective Surgery with
identified risk factors
Emergency major
surgery
Parenteral controlled
substances
Drug treatment
requiring intensive
monitoring
Decision not to
resuscitate or deescalate care because
of poor prognosis
54
How to Steps of Coding:
Determine Level of History Component

History component consists of three
sections:
● History of Present Illness (HPI)
● Review of Systems (ROS)
● Patient, Family, and Social History (PFSH)
55
Determine Level of History Component
Section I: History of Present Illness








Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms
56
Determine Level of History Component
Section II: Review of Systems














Constitutional symptoms (fever, wt loss, etc.)
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurologic
Psychiatric
Endocrine
Hematologic/lymphatic
Allergic/immunologic
57
Determine Level of History Component
Section III: Patient, Family and Social History



Past medical history
● Medication allergies
Patient’s family history
Patient’s social history
● Age-appropriate review of past and
current activities
● Tobacco usage
58
History Component Matrix
(Number of components of each HPI,
ROS & PFSH required for each level)
New
99201 99202 99203
99204
99205
Established
99211 99212 99213
99214
99215
HPI
0
1
1
4
4
ROS
0
0
1
2
10
PFSH
0
0
0
1
2
59
How to of Coding Steps:
Determine Level of Physical Examination












Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskletal
Skin
Neurologic
Psychiatric
Hematologic/Lympatic/Immunologic
60
Determine Level of Physical Examination:
# of body systems required for each level
New
99201
99202 99203 99204 99205
Established
99211
99212 99213 99214 99215
Exam
0
1
4
5
8
61
Coding Matrix Example:
New Patient
History
3
Established
Patient
3
Exam
2
2
Medical
Decision
Making
Level of Coding
3
3
2
3
62
Coding Matrix Example:
History
New Patient Established
Patient
4
4
Exam
2
2
Medical Decision
Making
4
4
Level of Coding
2
4
63
Coding Exercise
64
Coding Exercise for Evaluation/
Management Services
Suzy Q is a 16 y/o female with c/o
severe “female” cramps - worse than usual.
She states she took Midol and it only
helped a little. She is a new patient.
Document on the exam and encounter
form to a level 3, using audit sheet
as reference.
65
66
67
How to Verify this is correct
level of documentation to
support level 3
68
69
Count the components
HRI 1 - Midol
Exam 1-const
Med Decision
ROS 1 - cramps
2-Abd
- acute/uncomp
PFSH - 0
3-back
- OTCs
4-genito
___________
____________
___________
Level 3
Level 3
Level 3
70
71
Preventive Services
72
Preventive Services

These visits include a
comprehensive history and
examination, as well as appropriate
counseling/anticipatory
guidance/risk factor reduction,
interventions, and the ordering of
age-appropriate
laboratory/diagnostic procedures.
73
Preventive Services

“Comprehensive” in a preventive
service examination is not synonymous
with a “comprehensive” E/M
examination.
74
Preventive Service Codes
Age
<1
1-4
5-11
12-17
18-39
40-64
65+
New
99381
99382
99383
99384
99385
99387
99387
Established
99391
99392
99393
99394
99395
99397
99397
75
Preventive Services
Appropriate ICD-9 codes would be:

V20.2 for a Routine Infant or Child Health
Check

V70.3 for a Sports Physical
76
Preventive Services

Additional services provided at the time
of the visit should be reported with their
specific CPT codes listed separately:
● Examples:
● Snellen Test
● Laboratory
● Immunizations
● Administration of Immunizations
77
Common Pitfalls in
Coding
78
ICD-9 CM (Clinical Modification)
Coding Guidelines
Order to list ICD-9 codes
Coding Order is Important
1.
2.
3.
Acute Reason patient is being seen
needs to be listed first.
Co-morbid diagnosis affecting treatment
of principal diagnosis are listed next.
List all other documented conditions
coexisting at the time of the visit that
require or affect patient care, treatment or
management. Chronic diseases may be
listed as often as they are treated
79
ICD-9-CM Coding Guidelines

DO NOT CODE:
● Conditions previously treated that no
longer exist.
● Conditions that do not affect treatment
or management at the current visit.
● Rule-out, suspected, questionable or
probable diagnoses.
80
ICD-9-CM Coding Guidelines
Review of Systems Documentation
Cannot say “all other negative”
 Must list pertinent and negative
findings
 Must have a way to determine which
systems were reviewed
 A check list is acceptable

81
About Time With the Patient
Do not base your level of service on
time spent with patient.
 Time only comes into play if you are
billing for counseling within an acute
visit or if all you are doing is counseling

82
Sports Physicals
They are not meant to be
comprehensive physicals – their focus
is different
 Check www.aafp.org for an appropriate
form
 You can bill for a complete PE and a
sports PE within the same year

83
Acute Problems within a
Comprehensive Physical


When doing a preventive health visit
(V20.2) and there is a separate health
acute problem – you can list both the
preventive health visit code (first) and the
acute visit code (second) – BUT THERE
MUST BE ICD-9 CODES THAT JUSTIFY
BOTH
(the billing department must add a
modifier)
84
Be sure to know the
Reason for the Visit
Reason for
Visit
Preventive
Visit
Acute
Visit
Counseling
Visit
85
Late Effects of Burns
Late effects means the burn has healed.
There should not be dressing changes.
86
Counseling Visits
Counseling visits are when
client comes in to discuss a
problem only. No hands are
laid on the patient.
87
Example
Dietary Surveillance & Counseling
There must be a dietary problem in
order to justify this code.
88
Be Specific with the
codes you use
89
784.1 Throat Pain

EXCLUDES:
● Dysphagia 787.2
● Neck pain 723.1
● Sore throat 462
● Chronic 472.1
90
AGAIN - About
Over-coding and Under-coding
CPT and ICD-9 codes must always
relate
 The first ICD-9 code you use drives the
relationship to the CPT code

91
Poor example incorrect coding for
documentation
See Handouts of Completed Note
Sample 10a (handout 9)
&
Encounter Form 10a (handout 10)
92
93
94
Analysis of incorrect coding
for documentation
95
Coding Audit Cheat Sheet
Top half of form
PATIENT IDENTIFIER____10a
CODING AUDIT CHEAT SHEET
TYPE OF SERVICE PROVIDED:
Preventive Health – New patient
______
Preventive Health – Established patient ______
Counseling Services– No Physical Complaint
Is time recorded in chart?
YES _____NO _____
Is a counseling code used?
YES _____ NO _____
Evaluation / Management Visit: where counseling determines time
Is the total time of the visit recorded
YES _____NO _____
Is the time spent in counseling recorded
YES _____ NO _____
Is a counseling code used?
YES _____ NO _____
Evaluation / Management Visit – NEW PATIENT
Evaluation / Management Visit – ESTABLISHED PATIENT
CPT & ICD-9 CODES USED
CPT CODES: 99203
ICDE-9 CODES:
625.3
DO THE CPT/ICD-9 CODES
CORRELATE?
YES __X___NO ______
96
Coding Audit Cheat Sheet
Bottom Half of Form
HISTORY AND EXAMINATION


New
Established
99201
99211
99202
99212
99203
99213
99204
99214
99205
99215


HPI
ROS
PFSH
0
0
0
1
0
0
1
1
0
4
2
1
4
10
2

EXAM
0
1
4
5
8

CHART AUDIT LEVELS FOR E/M VISITS

HPI, ROS, PFSH
3

EXAMINATION
2
2
NEW PATIENT LEVEL
Lowest level supports level
ESTABLISHED PT LEVEL ____
2 of 3 or middle level supports level

MEDICAL DECISION MAKING
3
97
Medical Decision Making
Section I: Diagnosis or Management of Problems
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
One selflimited or
minor problem
Two or more selflimited or minor
problems
-One stable
chronic
condition
-Acute
uncomplicated
illness
One or more chronic
illnesses with
complications
Two or more stable
chronic conditions
Undiagnosed new
problem w/uncertain
prognoses
Acute illness with
systemic symptoms
Acute complicated
injury
One or more chronic
illness with severe
complications
Acute or chronic
illness or injury that
is life or limb
threatening
Abrupt change in
neurologic status
98
Medical Decision Making
Section II: Diagnostic Procedures
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Lab
X-ray
EKG
UA
Ultrasound, etc.
Venipuncture
KOH
Physiologic tests
not under stress
Pulmonary
Function
Barium Enema
Arterial puncture
Skin biopsies
Physiologic tests
under stresscardiac stress
tests
Diagnostic
endoscopies with
no risk factors
Deep needle or
incisional biopsy
Obtained fluid
from body
Cardiovascular
imaging with
contrast
Cardiovascular
imaging with
contrast
Invasive diagnostic
tests
Cardiac
Electrophysiological
tests Diagnostic
endoscopies with
identified risk factors
Discography
Other levels of Diagnostic procedures do not usually apply to SBHC, but you only
need to have 2 of the 3 areas of medical decision making to agree.
99
Medical Decision Making
Section III: Treatment or Management Options
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Minor surgery with risk
factors
Elective major surgery—
no risk factors
Prescription drug
management
IV fluids with additives
Closed facture or
dislocation treatment
w/o manipulation
Therapeutic nuclear
medicine
Elective Surgery with
identified risk factors
Emergency major
surgery
Parenteral controlled
substances
Drug treatment
requiring intensive
monitoring
Decision not to
resuscitate or deescalate care because
of poor prognosis
Rest
Gargles
Elastic
bandages
Dressings
OTCs
Minor surgery
PT
OT
IVs without
additives
100
Unfortunately – Because of this
documentation/coding error - you
will not get paid for this visit.
This is why it is very important to
verify that
charting supports
all levels of coding decision
making.
101
Questions & Answers
102