Coding Clinical Encounters Definition of Terms: CPT E/M and Procedure Codes The CPT E/M section is divided into broad categories such as office visits, hospital visits, and consultations CPT Procedure Codes are based upon the specific procedure being performed. National Correct Coding Policy Applies to services billed by a single provider for a patient on the same day Some CPT Procedure codes have been developed that are considered “comprehensive” These CPT Procedure codes incorporate the E/M service; therefore the E/M Code should not be coded The RVU assigned to these CPT Codes are based on the comprehensiveness of the procedure (i.e., incorporate the “value” of the E/M service) However, ADM 3.0 software requires an E/M to be coded CCI EDITS Audit checks to ensure (and deleted if found) additional codes are not billed with comprehensive or exclusive codes RVUs Relative Value Units (RVUs) Since 1992, reimbursement (payment) to providers has been based on a fee schedule using RVUs RVUs are a nationally recognized measurement of the resources (the amount of time, effort and intensity) required to provide a particular service or procedure Every CPT E/M and Procedure Code has an RVU assigned, but some are ZERO RVU is multiplied by the standard conversion factor to get the “payment amount” RVUs are tracked as an indication of provider workload ICD 9 CM Diagnosis What’s the Same? Same method for deciding the diagnostic code Refer to flow sheet and superbills Can code up to four diagnoses V71.09 and 799.9 are not recommended for use; Code presenting symptom or chief complaint What’s Different? New Codes for Consultative BH Care in medical clinic New method for deciding the CPT E/M and procedure Codes ICD 9 CM Diagnosis The type of diagnosis (psychiatric or physical) now guides the type of CPT E/M and Procedures Codes to use PSYCHIATRIC Diagnosis (YELLOW on Superbill in Appendix 11) PHYSICAL Diagnosis (PEACH on Superbill in Appendix 11) Use 99499 (E/M) along with 90801 (new patient) or 90804 (follow-up patient) for CPT Procedure Use 99499 (E/M) along with 96150 (new patient) or 96152 (follow-up patient) for CPT Procedure OR Use 99242 (consultative E/M code) for any “new patient”, regardless of diagnosis, with NO CPT Procedure Code E & M Codes If using a CPT Procedure code, then use 99499 (unlisted E/M Code) because the CPT Procedure Codes used for BH in primary care are Comprehensive Codes Telephone contacts are types of CPT E/M codes – 3 types DO CODE these DO NOT code a CPT Procedure code with telecons Consultation E/M Codes Consultation E/M Codes (99241, 99242) Consultations are provided at the request of another provider, to render an opinion or advice regarding the evaluation and management of a specific problem. You must document the need in the patient’s record You may initiate diagnostic and/or therapeutic services, such as writing prescriptions or initiating treatment plans. You must document the opinion you render and services you order or perform in the patient’s medical record. Report this information to the requesting provider. Report separately any identifiable procedure or service performed on, or subsequent to, the date of the initial consultation. When you assume responsibility for the management of any or all of the patient’s care subsequent to the consultation encounter, consult codes are no longer appropriate. BH CPT Procedure Codes Two Categories of BH CPT Procedure Codes Health Behavior Assessment and Intervention (96150-96155) – Use “quantities” for these Psychiatric (90801; 90804, etc) Both sets of CPT procedure codes are ‘comprehensive’ and have CCI edits Use 99499 E/M code (unlisted E/M code) with these Use diagnosis to determine which category to use Can code multiple CPT Procedure codes for one visit (but not same CPT; if same CPT use quantities) For example, using a CPT procedure code for health risk assessment (99420), but there are no RVUs for this service If you choose to use a consultation E/M code, do not also use a CPT Procedure code. Use only for initial BHC consultation visits. (there is no ‘right’ answer) Coding Logic CPT CODES Non-Consultative Codes Consultation E/M Codes (99499 E/M Code plus CPT Procedure Code determined from logic below) (99241, 99242, 99243) Psychiatric ICD-9 CM Diagnosis Physical ICD-9 CM Condition/Diagnosis (Use CPT Procedure Codes 90801, 90804) (Use CPT Procedure Codes 96150-96155) Examples P A T IE N T TYPE N ew P atien t REFERRAL Q U E S T IO N / P R E S E N T IN G PRO BLEM H ead ach e IC D -9 CM CODE E /M CODE CPT CODE 7 8 4 .0 99499 96150 RVUs .7 2 x 2 = 1 .4 4 x co n sta n t ($ 3 6 .2 0 ) = D o lla r V a lu e E q u iv a len t $ 5 2 .1 3 Examples P A T IE N T TYPE REFERRAL Q U E S T IO N / P R E S E N T IN G PRO BLEM IC D -9 CM CODE E /M CODE CPT CODE RVUs x co n sta n t ($ 3 6 .2 0 ) = D o lla r V a lu e E q u iv a len t N ew P atien t R /O A n x iety D iso rd er 3 0 0 .0 1 99242 ------- 1 .8 8 $ 6 8 .0 6 N ew P atien t H ead ach e 7 8 4 .0 99242 ------- 1 .8 8 $ 6 8 .0 6 F o llo w -U p P atien t H ead ach e 7 8 4 .0 99242 ------- 1 .8 8 $ 6 8 .0 6 Examples P A T IE N T TYPE REFERRAL Q U E S T IO N / P R E S E N T IN G PRO BLEM IC D -9 CM CODE E /M CODE CPT CODE RVUs x co nsta n t ($ 36 .2 0 ) = D o lla r V a lue E q u iv alen t N ew P atien t D ep ressio n 2 9 6 .3 0 9 9 4 99 9 0 8 01 3 .7 9 $ 1 3 7 .20 N ew P atien t S leep D istu rb an ce, U n sp ecified 7 8 0 .5 0 9 9 4 99 9 6 1 50 .7 2 x 2 = 1 .4 4 $ 5 2 .1 3 Examples PA T I E N T TY PE REFERRAL Q U ESTIO N / PR E SE N T IN G PR O B L E M IC D -9 E /M CM CODE CODE CPT CODE RVU s x c o nsta nt ($ 3 6 .2 0 ) = D o lla r V a lue E q uiv a le nt F ollo w - U p Pa tie nt Ins o m n ia 3 0 7 .4 2 99499 90804 1 .6 4 $ 5 9 .3 7 F ollo w - U p Pa tie nt D ia b etes M a na g e m e n t 2 5 0 .0 2 99499 96152 .6 6 x 2 = 1 .3 2 $ 4 7 .7 8 F ollo w - U p Pa tie nt D e pr essio n 2 9 6 .3 0 99499 90804 1 .6 4 $ 5 9 .3 7 Review and Questions Review Mini-Guides in revised Appendix Questions from participants ? Questions ?