B4: Crack the Code:
Addressing Billing Code Issues
Laura Brey, Training Director, NASBHC
lbrey@nasbhc.org
919-866-0920
Welcome and Expectations
2
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
– Explain the rational for conducting routine
medical record review and coding compliance
audits in SBHC settings
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
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

18
Coding Does Not
Equal Good
Medicine
19
But - Coding is Good
Documentation
20
CPT Codes document:

Level of Service

Procedures Provided
21
Examples of CPT codes
Evaluation
&
Management
99211
99212
99213
99214
99215
Preventive
Health
99391
99392
99393
99394
99395
99397
99397
22
ICD-9 and DSM4 Codes
document:
The reason behind the visit
(They must support the CPT codes)
23
General Coding Principles
Coding gets you paid for your services
 Coding can be used to justify the need
for services to your funders

24
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
25
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
26
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)
27
“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
28
“V” Codes

Can be used as a:
– Solo Code
– Principal code
– Secondary code

May represent check-ups, screenings,
administrative requests, prescription
refills
29
Rules for Coding
Outpatient Visits
30
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
31
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.

32
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

33
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
34
Evaluation/Management
(E / M) Services

Beginning information about coding
deals with the three key components:
– History
– Examination
– Medical Decision Making
35
Evaluation/Management
(E / M) Services
There are 5 Levels of service
1.
2.
3.
4.
5.
Minimal
Self-Limited or Minor
Low Severity
Moderate Severity
High Severity
36
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
38
Coding Steps
39
Coding Steps

First Step - Determine if your patient is:
A New Patient
or
An Established Patient
40
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
41
If your patient does not
meet the definition of a
New Patient,
then they are an
Established Patient
42
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
43
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
44
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
45
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
46
Example – Established Patient
HPI, ROS, PFSH
3
This is the middle level
EXAM
2
Medical Decision Making
4
47
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)
48
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
49
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
50
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
51
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
52
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)
53
Determine Level of History Component
Section I: History of Present Illness








Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms
54
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
55
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
56
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
57
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
58
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
59
Coding Matrix Example:
New Patient
History
3
Established
Patient
3
Exam
2
2
Medical
Decision
Making
Level of Coding
3
3
2
3
60
Coding Matrix Example:
History
New Patient Established
Patient
4
4
Exam
2
2
Medical Decision
Making
4
4
Level of Coding
2
4
61
Coding Exercise
62
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.
63
64
65
How to Verify this is correct
level of documentation to
support level 3
66
67
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
68
69
Counseling /Education Only
During and E and M Visit
70
CPT Codes Used for
Counseling/Education Only
E and M Visits
New Patients
Established Patients
10 minutes 99201
20 minutes 99202
30 minutes 99203
45 minutes 99204
60 minutes 99205
5 minutes 99211
10 minutes 99212
15 minutes 99213
25 minutes 99214
40 minutes 99215
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
Coverage Issues


A provider should
know what services
are covered.
Services must be
documented and
medically necessary
in order for payment
to be made.

Do you, as a provider,
know if all services
provided are covered?
Are you documenting
properly, and what about
this “medically necessary”
bit?
How Much are you Paid?

Reimbursement
– Reductions in reimbursement rates by
provider type
Physician
- not discounted
 NP or PA
- sometimes discounted
 Clinical Psychologist
- discounted
 LCSW
- further discounted
 Other
- discounted if
covered

Reimbursement Issues

E&M codes are limited to physicians, PAs,
NPs, nurses

Same is true for 90805, 90807, 90809 codes

An E&M (992XX) and a therapy (908XX)
cannot be billed on the same date of service
to most Medicaid programs
Documentation and Coding:
Fraud and Abuse

Services MUST be medically necessary
(determined by payers based on a review of
services billed)

Music, game, instrument, pet interaction
therapies, sing-alongs, arts and crafts, and
other similar activities should not be billed as
group or individual activities.

Services performed by a non-licensed provider
particularly as “incident to” using the PIN of the
licensed provider
Elements of “Incident To”

An integral part of the physician’s professional
service

Commonly rendered without charge or
generally not itemized separately in the
physician’s bill

Of a type that are commonly furnished in
physician’s office or clinic

Furnished under the physician’s direct
personal supervision
Common Pitfalls in
Coding
83
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

84
Sports Physicals
They are not meant to be
comprehensive physicals – their focus
is different
 Check www.aap.org for an appropriate
form
 You can bill for a complete PE and a
sports PE within the same year

85
Counseling Visits
Counseling visits are when
client comes in to discuss a
problem only. No hands are
laid on the patient.
86
Example
Dietary Surveillance & Counseling
There must be a dietary problem in
order to justify this code.
87
Be Specific with the
codes you use
88
Coding Compliance
Audit
89
Questions & Answers
90