JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
JSI RESEARCH AND TRAINING INST
Speaker: Lissa Singer, MBA, RNP, CPC-I
Introduction to Coding and Documentation for STD Services
August 7, 2013
Lissa Singer:
Good Morning or Good afternoon to everyone out there depending on what coast you’re
on. I really am thrilled to be here today to talk to you about coding for STI services.
We do have a few learning objectives for today’s presentation. I hope you all walk away
with a basic understanding of ICD-9 or International Classification of Disease or Diagnoses
coding. I hope you walk away with an understanding coding for evaluation and
management visits which is the bulk of what you do. I hope you understand coding for
basic office procedures with the use of modifiers.
The next slide just talks about the fact that I am going to give you a lot of great information
today but your billing and coding decisions are your own.
When we talk about coding its necessary to think about coding in the perspective of what’s
medically necessary to do. Where do you turn to for a good definition of medical necessity
of course Medicare and Medicaid has a good definition and I am going to just read it to
you: “A service that is reasonable and necessary for the diagnosis and treatment of illness
or injury, or to improve the function of a malformed body member.”
Hopefully you don’t see a lot of that in your service. It’s generally considered to be a
service consistent with the symptoms or diagnosis; Consistent with what is generally
accepted in terms of medical standards; Not done for the convenience of patient or provider
– it other words let’s just get everything done today because just it’s easier; Needs to be
rendered at the most appropriate level.
I am going to give you a lot of great information today. You are going to be able to
document for very high level services. The most important thing is the questions that you
ask and the exam that you do and the prescriptions or the treatments that you do are
considered medically necessary and rendered at the most appropriate level.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Everyone always asks me at the end of a presentation am I ever going to go to jail. I can
tell you I have been doing this for quite a long time and no one I have ever known has
ever gone to jail for over-coding or under coding or fraud or abuse. But it is important
that you know the definitions or fraud and abuse. The worst thing that could ever
probably happen to you is you would have to pay back some fines but you won’t go to
jail. The government has great definitions for fraud and abuse.
Over coding is billing for high or more complex services than was actually rendered.
That is considered fraud.
On the flipside, under coding is also considered fraud. And again that just goes back to
Medicare and because Medicare clients have to pay a co-pay based on the cost of their
visit and if you under code they can actually afford to come back more frequently which
encourages frequent fliers. Unfortunately, you don’t get your money back if you’re under
coding – they also consider that just a little bit fraudulent as well. Waving a co-pay for
commercial insurances and Medicare and Medicaid is also considered fraud. They
consider it your responsibility to collect the co-pay and their responsibility is to pay you
the remainder of the visit. However if you do have a policy for financial need you can use
that to wave a co-pay on an occasional basis. And then the last is falsely establishing
medical necessity. This is considered reporting false or inaccurate diagnosis codes. That
is considered abuse.
Before I actually get into the talk about coding let’s talk a little bit about how you might
be credentialed with the payer. There is a type of billing called incident to billing Incident
to billing is considered billing as if the supervising provider was the provider who saw
the patient. So allied health professional bills as if the medical director or physician who
is in the practice saw the patients himself. I need to just tell you this sounds great because
you only have to credential 1 or 2 people. But there are multiple limitations when you do
this type of billing. You can’t see any new patients or any established patients with new
problems. And for most payers the doctor needs to be directly onsite if you use this time
of billing. Medicaid and Medicare and many of the commercial insurances do enroll
Allied Health professions: PA, NPs so I would consider you to consider both sides of the
coin when thinking about how you’re going to credential your providers. Also know that
when you individually credential your PA’s and NP’s you will take a slight decrease in
pay – 10-20% depending on who the payer is.
Let’s move on to the basics about coding. There are a couple of basics like “who,”
“what” “why” “where” and “when.” The first is your ICD-9 Codes or your International
classification of disease codes. Those are your diagnosis codes. That’s why you did what
you did. Your CPT codes or your current procedure terminology codes are your “what.”
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Modifiers are the exception to the rule and they are “the additional info.” You also have
HCPCS codes or Health Care Common Procedure codes – they are the “what else.”
Let’s talk about ICD-9 codes. They are the why or what you do. They are alpha-numeric.
They are 3-5 characters long with a decimal point in there somewhere. It’s important to
have the most current ICD-9 codes because if you’re off by just one digit your claim can
be denied because they don’t recognize the ICD-9 code. When you get an ICD-9 book,
usually it’s divided into two volumes – volume 2 and volume 1. It’s very important that
you look up in volume 2 the diagnosis that you are looking for. So if it’s vaginal
discharge, chlamydia, gonorrhea, you look it up in volume 2 in the alphabetical index and
it will immediately give you an ICD-9 code. But then I caution you – then look up the
ICD-9 in the index in the front of the book and that will give you much more information
about the ICD-9 code that you are about to select. There are some codes that begin with
the letter V and I will tell you to use these as a last resort.
When you look up your ICD-9 codes it’s very important to use the most specific code
available. It’s very common for people to use cheat sheets. You’re not doing the full
range of family planning or family practice so your diagnosis codes are going to strictly
be around sexually transmitted infections. Most of them will fit on one page – maybe half
a page so you will have them available to you. Use a cheat sheet and definitely update it
every year because there are changes. These ICD-9 codes are not just used for
reimbursement they are used all over the world to classify diseases and to see how many
people in the United States have hypertension or gonorrhea – so important for statistics as
well. Just as you are getting used to ICD-9, get ready for ICD-10 which is available in
October 2014. It is a much better coding system. You will find it a much more detailed
coding system.
There are seven ICD-9 usage guidelines and they will remain the same for ICD-10. It
very important to identify all the diagnosis, symptoms and conditions and link them
appropriately. Any diagnosis, symptom or condition affects your treatment plan that day
definitely code it.
List the primary condition first. That is the one you perceive as most important that day.
Definitely utilize all five digits if possible and be as specific as possible. Probable,
suspected, rule out, diagnosis should not be coded. It’s okay to put in notes. Don’t code
unless you are absolutely sure.
You can code chronic diseases as many times as the patient receives treatment. Code
diagnosis for which service is performed; if the diagnosis is different after service list
new diagnosis only. This is generally for biopsies -- wait for pathology report to come
back so you can use most appropriate diagnosis code. And the last of the usage guidelines
is do not code what no longer exists and I will tell you there is one caveat for that. When
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
your patients come back for a rescreening you still can use whatever you are screening
them for because at the time you are doing the visit you don’t know if they still have it or
they have been infected.
The next couple of slides are ICD-9 examples. They are just for your reference – things
that you might want to put on your cheat sheet.
What happens when you don’t have a diagnosis or the patients have no symptoms? Here
you will be forced to use a V code. Here are some V-code examples: V15. 85 is a
personal history of contact with and suspected exposure to potentially hazardous body
fluids -- so when the condom breaks you could use this code.
I will caution you to use the next V69.2 – high risk sexual behavior because your ICD-9
codes have a life longer than the claim. This diagnosis code made actually label the
patient so use this with caution. Some special screening codes are available to you in this
slide and in the next slide is just a number of V codes that is available for your reference.
Okay, so let’s talk about the meat of what you do and that’s the current procedural
terminology (CPT) codes. That’s the “what.” They are always going to be 5 numeric
characters in length. We are going to focus today mostly on evaluation and management.
office visits, preventative visits and hospital visits are all considered evaluation and
management codes. We are only going to talk about office visits today. And we are going
to talk about some surgical procedures. In the surgical section the range is everything
from cardiac bypass to wart removal – major to minor procedures.
So here is the CPT code range breakdown. 99201-99499 is where the Evaluation and
Management codes live and it’s highlighted today because it’s where we are going to
spend most of our time today. You have codes for anesthesia, surgery, radiology,
pathology and medicine and that is the code break down as well.
There are some “what—else” codes and these are the healthcare common procedure
codes. Again, these can be from 3-5 alpha-numeric characters in length. And here are
some J codes that you might use if you’re paying for your own antibiotics and then giving
them to patients at the visit. These are available for your reference and are current for
2013 and are treatments you might use for an STI clinic.
Let’s talk about ranking and linking. So when you see a patient and this is just an
example. The example is a woman with pelvic pain and the diagnosis code is there for
you. The woman has pelvic pain and condyloma today. This is ranked the providers
perceived acuity. The pelvic pain is more concerning to the provider than the condyloma.
The service that the provider provided was a 99214, a level 4 service. There is a 25
modifier there for a level 4 established patient. This provider saw this patient for both of
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
these problems and then did minor surgical procedure which is destruction of the vulva
lesion, which is the 56515 – but she only did this procedure for the condyloma, certainly
not for the pelvic pain. No you would think that payers should be able to figure this out
but they don’t. You have to be able to tell them that this is why I did this procedure and
this is why I did this office visit. People can come up with a number of very creative
ways to show the biller how you rank and link these together. But it is my opinion that
the provider ought to do this because the person in the back office may not be a clinician
and they need to know which is more important than the other. They might think the
warts are more important.
Alright, here is the CDPT code range break. On the left hand side of the slide your new
patient evaluation and management codes A level one is considered 99201, level 2 is
considered 99202 and you can get the picture. The ones in red are the ones that I believe
you in an STI clinic will use most frequently. Across from that is a range of
reimbursements that you might see. If you look at 99201 versus 99211 -- that is your
established patient level codes --is that the reimbursement are not the same for each level.
So a high range for a 99201 might be $50 and a high range for a 99211 might be $30.
Generally those hang in the 10-12-13 dollar range.
So why is that? They pay you more to see a new patient because if you’re a clinician you
absolutely know that it is more difficult to see a new patient – you have to get a full
history generally.
Your level of history, your level of exam and your level of decision making – each one of
these are independently scored. They equal your level of service. Now the centers for
Medicare and Medicaid came up with two sets of guidelines – one is 1995 and 1997 and
they call them the “CMS 95 & 97 Guidelines.” We are going to focus on the 95
guidelines today because they are the easiest to understand. The reason that CMS did this
is because there is not a lot of guidance for the code book. Even though CMS did this,
these are the guidelines that every payer uses. Why reinvent the wheel? Even if you are
not seeing a lot of Medicare patients these are the guidelines that most payers use.
It’s probably a very good idea to take out your handout. If you haven’t downloaded it yet,
the next two slides are identical to your hand out. But what I am going to teach you now
are the two rules about new patients and established patients. For a new patient, it
something called the 3 of 3 required. So a new patient office visit, your codes are on the
left hand side, then your history is the second column – “exam.” “MDM” stands for
“medical decision making” and then something called “time” in the last column. 99201
has a bunch of 1’s across for history, exam and medical decision making and for level 2
the same thing. Because each one of these elements is scored individually and then that
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
equals the level of service. So for a new patient it’s called the “3 of 3 Rule” and that is
the overall visit level is the lowest component score.
Let me just walk you through a number of examples. So the first example I am going to
give you is the patient has a problem focused history. That is a level 1 history. So hopeful
you find the level one right there. Then move to the exam column. This patient was well
documented and has a detailed exam – so a level 3 exam. And there was low complexity
medical decision making. So you have a level 1 history, a level 3 exam and medical
decision making that is also of level 3. But you need 3 of 3 in order to build that
particular level so you have to go to the lowest of the components. So in this particular
case – a problem focused history, a detailed exam and low complexity decision making is
a 99201.
Now I promised to talk to you about what all these other abbreviations are HPI, ROS.
That’s coming. But what’s really important is that you learn the 3 of 3 rule and 2 of 3 rule
which I will talk about next.
But let me just give one more example. For a new patient the next example is – take a
look at the history column and we will go to a detailed history. So this person has a
detailed history and a detailed exam, a level 3 exam with straight forward medical
decision making. So we have a 3, 3, and a 2. And in this case it’s going to be a 99202.
Hopefully that is pretty clear to you. Let’s move on to established patients. But before I
do let’s go back for 1 sec. I just want to talk about the definition of a new patient. A new
patient is a patient that hasn’t had face to face service by a provider of the same specialty,
within the group pack, within the same group practice, within the past 3 years. So what’s
obvious is someone you have never seen before walks into your clinic as a new patient.
But it could also be one that hasn’t been seen in three years. What’s also to note here is if
you’re a large clinic agency and you have a number of satellites or sites all over the state
or all over your city and you are using one tax ID to bill which most people do. If it’s a
new patient, 5 days ago in one city or one location and then that patient goes to another
satellite – it’s not a new patient anymore even though you have never seen that patient.
Also, what also holds true is if a colleague of yours within the same clinic see’s that
patient on day 10 and you see him on day 20 – it won’t be a new patient.
So now let’s move on to established patient. So your established patient rule is
considered the 2 of 3 required. The 2 of 3 required rules is that the overall visit level is
the component score that’s in the middle. As you will notice, for a level 1 visit, a 99201,
there are not a bunch of ones straight across the columns. That’s because the provider is
not required for a 99211 visit, the patient does have to be seen previously by a provider
and this is just to follow up for a problem.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Okay, so again we have the codes on the left hand side of the column and history, exam
and medical decision making – each one individually scored.
In this case it’s the two of three rule so let me give you a couple of examples. The first
one is – let’s say the patient has a problem focused history – that’s a level 2 history. The
exam is expanded problem focused, so that’s a level 3 exam. The decision making in this
case would be a level 4 – that’s moderate complexity medical decision making. What I
tell folks to do is put these components in numerical order and then take the one that’s
directly in the middle. So in this case you have a level 2 history, a level 3 exam and the
medical decision making is a level 4. You’re going to take the one that’s in the middle –
that’s a 99213.
How about if I give you one more example? Let’s take a detailed history so a level 4
history, and a detailed exam, a level 4, and low complexity medical decision making. So
you put them in numerical order: 3, 4, 4. You are going to take the component that’s in
the middle so a 4 and its going to be a 99214. Alright, hopefully that’s clear to you. I can
certainly explain it one more time if you have questions at the end.
Let’s talk about as I promised each one of these individually. We’re going to talk about
the history first. Your chief complaint is required for every visit. That’s the reason for the
visit. But as you know that’s not always the ICD-9 code. The patient may come in with a
long list of things. The patients’ idea of what might be important that day might not be
your idea. It’s important though that you write what the chief complaint is – whether it is
vaginal discharge, penile discharge, a lump, a bump, a rash, a drip -- whatever it is. It
should be a statement in the patient’s own words. Be as specific as possible in the chief
complaint.
A history of the present illness which is also abbreviated as HPI consists of 7 things –
duration, timing, severity, location, modifying factors – so what makes it better what
makes it worse -- associated signs & symptoms, and context.
I have another slide to delineate that for you. The location is not where it happens. So if a
condom broke in bed last night – that’s not where it happened. It’s the area of the body
that you are concerned with. The rest of the definitions you can clearly read on your own.
Modifying factors I will explain. That’s what makes it better, what makes it worse. If its
pain, maybe Tylenol helps. If its vaginal discharge maybe the patient tried something
over the counter and maybe it helped or it didn’t help.
Context happens to be any circumstance around the event. In this example its saying the
pain occurs when the patient is climbing stairs. But it really can be just about anything
that gives you more information about that chief complaint.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Associated signs and symptoms is any problem associated with the chief complaint. I will
caution you to not use associated signs and symptoms in the history of present illness as
you have many other choices. You will see why this is important in a minute or two.
Okay history continued. So we have talked about the chief complaints, we’ve talked
about history of present illness.
Now let’s talk about “Review of Systems,” also abbreviated as ROS. These are signs and
symptoms related to the medical complaint.
Past Medical, Family & Social History also abbreviated as PFSH. So your past medical
history could be things like allergies, medication list, other problems or surgeries. Sick
contacts at home could be considered family history. But I would imagine in your line of
business that family history probably isn’t important in what you’re doing. But certainly
social history could be important – whether they are smoker or whether or not they have
alcohol or drug use or whether or not their sexual history is considered a social history.
This cartoon stresses the importance of a good history. Patients can be tongue tied or
tongue trapped. Or they can tell the patient who rooms the patient something different
than what they tell you. So let’s put it all together with the next slide.
Okay, so as I promised here is putting it all together with what a problem focused history
is. So a problem focused history is just a chief complaint and 1 to 3 elements in that
history of the present illness. Things like duration, timing, quality, etc. You don’t need a
review of systems and you don’t need any past medical family or social history to meet
the documentation requirements for a problem focused history.
For an expanded problem focused history, again you need a chief complaint, 1-3
elements in HPI and 1 pertinent review of systems. Pertinent meaning pertinent to the
chief complaint. I am going to show you some examples of what an expanded problem
focused history looks like. The reason why I told you not to use associated signs and
symptoms in your HPI and label it as ROS, just using those three letters will help you just
in case you are ever audited. And remember a lot of this is just in case you are ever
audited. When you document ROS, and auditor can’t possibly think that’s part of HPI.
Okay, so a detailed history and I have this highlighted in blue because I think that most of
the documents that I read and records from nurse practitioners and PA’s look a lot like
this. The chief complaint, usually there are 4 elements in the HPI, as least two review of
systems and something pertinent for either a past medical, family or social history. And
that why I probably have this highlighted. It’s what you document the most and if you do
detailed history and it’s an established patient your half way to a level 4. It’s very easy to
get to – I will show you.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
A comprehensive history, I doubt in your mind, is going to be medical necessary. Not in
terms of the history of the present illness but it’s got to be medically necessary to
interview the patient in all of his systems. So maybe a very sick HIV patient, maybe a
very sick patient with pelvic pain, depending on what you’re doing I don’t think you’re
going to get to the comprehensive level.
So here are some examples that I promised. As you will notice the chief complaint is the
same in both of these – it’s just discharge. So in the first example the “expanded problem
focused history” example your history of the present illness is vaginal discharge for two
days. Vaginal is the location and two days gives me the duration. As I told you that ROS
--negative dysuria-- now you could easily classify the lump as HPI. But if you put those
three little letters there, and you are ever audited they can’t downgrade your history. So
the review of ROS in this case is negative dysuria that’s GU review of systems. That’s
an expanded problem focused history – so easy to get to.
Let’s go to detailed history. Chief complaint, again, discharge. In this case documented.
The documenter said the HPI was the patient complains of a white lumpy vaginal
discharge for two days, heavy flow in the morning and no change with Monistat. In this
we have quality for lumpy vaginal discharge, location for vaginal, duration for two days,
timing for morning and no change with Monistat. We actually have 5 elements here, we
only need 4. In terms of review of system, it’s a negative fever, that’s a constitutional
review of systems and negative dysuria. So I have two review of systems. In terms of
history – the patient has had 2 partners in the last 30 days. This is social history. This is
the kind of history that I am used to seeing from PA’s and nurse practitioner – when I do
audits as well.
Let’s look at the next example. We have an expanded problem focused history. Again the
chief complaint is the same: pelvic pain for both. In the HPI for expanded problem
focused history. This provider wrote that the patient was complaining of stabbing pain,
that gives me quality, for one day, that gives me duration. So I have two elements in my
HPI. The review of systems is “no fever” – that’s a constitutional review of systems.
Let’s move over to the detailed history. Again, what I am used to seeing from most nurse
practitioners and PA’s is – the chief complaint is pelvic pain. The patient is complaining
of stabbing, so that gives me quality. The location is the left lower quadrant and for one
day gives me duration. It’s also better lying down so that gives me modifying factors. I
have 4 elements in my HPI. The review of systems clearly labeled again, “no vaginal
discharge” – that gives me a GU review of systems and no fever. And again, for history,
the history is “no medications except for OCP.”
So there you had two history examples. We are going to move on to the exam. The exam
is very easy and not as complicated as the history. There is only one element – body area
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
or organ systems. So problem focused exam is you examination of less than one complete
body area or organ system. So for example if it’s a GU organ system, if you are just
looking at the external genitalia – that will be considered a problem focused exam.
If you are sitting with a patient and doing a lot of counseling about HSV or HPV and they
seem to be a little bit anxious or not – just your assessment of their affect can be
considered a psychiatric exam so if you put “no apparent distress” – that’s considered a
problem focused exam.
Two- four body areas or organ systems is an expanded problem focused exam. 5-7 body
areas or organ systems is a detailed exam and again, I don’t believe in the line of business
for the majority of what you do would be medically necessary – would be to examine all
8 organ systems. So problem focused exam and expanded problem focused exam is going
to be the bulk of what you do.
This slide just delineates for you what is considered a body area versus an organ system.
That is there for your reference.
Okay, we are more than half way done!
So, medical decision making. When I talk to folks about medical decision making I could
actually spend 4 hours on it and people’s eyes kind of gloss over. What I am going to do
for you is really abbreviate this. Medical decision making is based on three things. 1)
What’s the diagnosis and how are you going to treat it 2) What is the amount and
complexity of the data review – and that just basically means what labs are you going to
do, how are you going to figure out what is wrong with this patient and 3) what is the risk
of the overall disease or what it is you are going to do.
So I have defined these for you and given some common examples. If you have an
established problem that is not well controlled with an over the counter medication you
can consider that low complexity. If you have a new problem with an over the counter
medication, that is considered low complexity medical decision making. If you have an
established problem, a follow up problem, and you write a prescription, that is also
considered low complexity medical decision making. So if you look at your hand out you
would know that low complexity medical decision making is actually level 3 for a new
patient and also level 3 for established patient.
Let’s move on to moderate complexity medical decision making because I believe that is
where the bulk of what you do hangs. Moderate complexity decision making could be a
new problem with acute systemic systems – so that could be pelvic pain with a fever. It
could be treating three chronic problems at that visit. An example might HPV, SPV, BV
or recurrent yeast. A new problem with prescription drug management. Every time you
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
take out your prescription pad for a new problem it’s considered moderate complexity
medical decision making. If you look at your hand out you will realize that its level 4
medical decision making what it comes to both a new and established patient.
High complexity maybe rare in your line of business – but that would be a new patient
problem with a transfer to the emergency department. That would be somebody very sick
with HIV or very sick with pelvic pain.
So remember, every time you take out your prescription pad, its moderate complexity
decision making when you are treating a new problem.
So let’s talk about some of the coding examples and what they might actually look like. I
told that we would talk a little bit about the 99211 visit. There is a little bit of controversy
in the 99211 visit but I will tell you that for commercial insurance and Medicare only the
billing or supervising provider needs to be on site. Now I know that is not what most of
you do. Medicaid and that’s what most of your patients are probably going to have is
very forgiving in many of the states. What’s important for you to do is to find out what
your Medicaid rules are. For many clinics across the country it could be that the provider
is available within 15 minutes, that the provider is available by phone or that the provider
is available in an emergency. So it is important that you find out what the Medicaid state
rules are. For 99211, it can’t be a new problem that might be waged also by Medicaid.
This is just Lissa Singer’s opinion, should NP or a PA ever bill a 99211, it’s a new
diagnosis for any of these conditions CT/GC/HIV – I would say no. But that is just my
opinion.
Okay, let’s look at some documentation coding examples. I have done this all in format
which I am sure you are very familiar with. But you may use a different kind of form.
The chief complaint for this 99212. The patient is here for a urine chlamydia and
gonorrhea test. So we have a chief complaint. The HPI is unprotected sex for two weeks
and no discharge. So we have two elements in HPI that is a problem focused history. The
O or the observation is the patient is in no distress. And the results are pending and the
options are reviewed. In this particular case we have a level 2 history, level 2 exam and
level 2 medical decision making – this is a 99212. Look how easy that is.
So here is a 99213. Again the patient is here for a urine CT/GC. The patient again, had
unprotected sex two weeks ago. The reviews of systems are a G review of systems so the
patient had positive vaginal or penile discharge. A constitutional review of systems is no
fever. Again, a problem focused exam, no apparent distress. We didn’t even do an exam
and the assessment treatment plan is presumptive treatment of chlamydia. You can write
this in your notes all day long, but remember please do not code them as having
chlamydia yet. So use your sign and symptom: positive vaginal or penile discharge. It’s a
new problem and you wrote a prescription so in this particular case it’s a level 2 exam, a
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
level 3 history and moderate complexity which is a level 4 type medical decision making.
So a 2,3, and 4 – you take the one that’s in the middle and it’s a 99213.
Okay, the last example is a 99214. I think again, this is the type of documentation I am
used to seeing from most nurse practitioners and PA’s. The patient is here for their HSV
culture results. The HPI gives me a very basic context statement: “concerned about the
results and telling his or her partner.” The review of system denies any discharge and
denies any fever. In your exam the constitutional exam is well developed, well-nourished
female, the skin is warm and dry. The psych shows no signs of apparent distress. The
lymph shows no inguinal lymphadenopathy. Take a quick look at the external genitalia,
no lesions and no fissures. But you got the culture results back and its positive for HSV2
and likely a subsequent outbreak and you are going to treat this patient with acyclovir.
It’s a new problem for you even though the patient may have had it for a while. So again,
we have a level 3 history, a level 4 exam because its 5-7 body area or organ systems, and
moderate complexity medical decision making. A level 9, a level 4 and a level 4 – you
take the one in the middle and it’s a 99214.
Folks, I think this is what most of you document like. Whether you use a progress note,
or a formatted form – this is what I am used to seeing. It’s very easy to get to a 99214. I
think you would all agree that every piece of this history and exam is medically necessary
and of course so is the prescription.
I’ve got an example for you in the next two pages of a 99215. This is a patient who is
very very sick with pelvic pain but this is what it might look like. So that is there for your
reference.
So this little dog wants to talk a lot. He’s on the couch he says “actually, I’m fine. I just
like to have a place where I am allowed on the couch.”
Well…what if I told you that history in exam and medical decision making aren’t
necessarily required for every single visit that you do. When you spend more than 50% of
the time with the patient just counseling them about their STI, you can actually bill for
time just like lawyers do. So the rule is it’s only used when counseling or coordination of
care represent greater 50% of the time you spent with the patient. Unfortunately, that’s
face to face time with the clinician – not the RN. How do you find out what is the typical
time? In the hand out in that last column of both the new patient and the established
patient it gives you the typical times for each level of visit. So if you’re looking at your
hand out take a look at 99204. It says you need to spend 45 minutes with the patient. So if
you are going to do a 99204 and bill for a 99204, you have to spend more than 23
minutes talking to that patient.
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Speaker: Lissa Singer
8/7/2013
Let’s take a look at a 99214 for an established patient. That only requires 25 minutes
spending with the patients. So that means more the 13 minutes you have to talk – just
counsel them. I will say that probably happens a lot. So how do you document this?
I have an example. The patient was seen on the 15th of January. The clock time was
optional. You can put in the clock time – you don’t have to. So the patient comes in and
wants to follow up about the labs – positive herpes culture at the last visit. The HPI, or
the context is that they have finished the Valtrex and there are “no more sores.” You did a
very brief exam with no lesions present. But it says that this is a new diagnosis of herpes
and I spent 35 of 40 minutes describing: HSV 1& 2, viral transmission, treatment
episodic vs. suppressive, healthy behaviors to reduce outbreaks & safer sex. If you take a
second to look at this -- I spent 35 of 40 minutes – what is 40 minutes for established
patients? It’s a 99215. Now you may not spend all that time. It could be 20/40. But that
would not be more than half. It would have to be 20 of 25 for a 99214. That how you use
billing for time. I would probably say that the large majority of what you do – you may
not examine a patient every single time. And history, exam medical decision making are
not required. Now remember when a payer gets a bill for a 99214 or 5 or whatever it is –
they have no idea that you billed based on time so your documentation has to support
that.
Okay, I have for your reference a number of 2013 CPT codes for wart removal. You will
notice that each one of these tells you after the code that there is 10 days associated with
that code and what that means is that there is a global surgical package associated with
the reimbursement of that code. If you see that patient for any problem related to the
procedure that you did within 10 days of that procedure, its included in the
reimbursement and you cannot bill for it. You will also notice that for wart removals in
these particular examples, that they have a different a code for simple vs. extensive. So
let me just talk to you a little bit about that.
Simple vs. extensive. If you look up these codes in CPT it will not give any guidance
between what’s the definition. So my advice to you is make it a policy. You might decide
that simple for destruction on the penis is maybe 1-2 or maybe just 3 or 4 wart removals
versus destruction of lesions on the vulva which is simple which might be 2-3 or 3-4
versus extensive. If you’re documenting that it’s an extensive removal please be sure it
applies to your policies. Maybe it’s a very large wart – the size of a small broccoli head –
I am sure you have seen those. So simple versus extensive – it could be the number of
lesions, it could be the size of lesions.
Okay, so let’s just talk very briefly about modifiers. There are two modifiers that you are
going to be most interested in. The first one is – remember we just talked about that
global surgical package and everything that you do for a patient is included in the
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Speaker: Lissa Singer
8/7/2013
reimbursement in that 10 days. That’s everything you do related to that surgical
procedure. So if it’s unrelated to the surgical procedure – let’s say you see the patient on
day 5 for a urinary tract infection or an itch. You need to be able to tell pay the payer that
you saw the payer in this 10 day package but I saw them for a reason that was totally
unrelated to the wart removal. Again you would think that the biller would be smart
enough to figure this out but you need to tell them. This modifier 24 is appended to the E
and M code. But again, you need to tell biller that it is unrelated because they are not
going to know.
What happens if you do an evaluation and management and procedure on the same day?
So if you’re doing a wart removal and the patient comes to you with lumps and bumps
and you do the diagnosis with the warts and the patient has time to stick around for wart
removal and you do an evaluation and management maybe a low level visit, level 2 or 3
or maybe level 4, and you do a wart removal you have to tell the payer “hey, I did two
things today and I need to be paid for both.” You do this by using the 25 modifier that
gets appended to the CPT code.
Okay, we are done with the bulk of the coding. People always like to talk about case
studies. I have two case studies.
So in the first case study the nurse practitioner or PA performs an expanded problem
focused history – so take out your cheat-sheet there – so find expanded problem focused
history on both the new and the established. He or she performs a problem focused exam
and the medical decision making was of moderate complexity. This nurse practitioner
was not at today’s training and asks for your help because you were here today.
Diagnoses for this patient are CT/GC.
Okay so here are the questions. If this was an established patient problem office visit,
what would the code be? Take a moment to take a look at that. So it’s an expanded
problem focused history a problem focused exam and moderate complexity medical
decision making. So if it’s established patient we are looking at a level 3 history, a level 2
exam, and moderate complexity which is level 4. So if you have a 2, 3, and 4 it’s going to
be a 99213. Hopefully you got that.
If this was a new patient problem office visit what would the code be? Really all you
have to do is know that it’s a problem focused exam and you go to the lowest because
that is the lowest – it’s a 99202.
Would you tell her she needs to go to the next training session? I hope your answer
would be yes to that.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
The next case study. This NP/PA lost his coding cheat sheet and he asks for your help
coding this office visit today for this established patient. So the patient comes in and the
chief complaint is “I think I have an STI.” The HPI is severe vaginal burning for 3 days
and took cranberry capsules without effect. We have a ROS with no fever or chills but
positive vaginal discharge. She is a non-smoker. So hopefully you have figured out that
this is a detailed history. There are 4 in the HPI, 2 ROS, and social history. This makes
this a detailed history. For the exam I have a constitutional exam, I have a vital sign
patient looks well, I have an abdominal exam, no CVA or supra pubic tenderness and I
am going to check urine for CT/GC. So only two organ systems examined today, that’s
an expanded problem focused exam. But I am going to treat presumptively for this new
problem with azithromycin so I am taking out a prescription pad for a new problem that
is moderate complexity.
How will you help this NP/PA to code this office visit? I hope you didn’t lose your cheat
sheet because I think this will be an invaluable tool for you. So for this established patient
we have a detailed history, so a level 4 history. We have an expanded problem focused
exam – a level 3 exam. And we have moderate complexity medical decision making. So a
level 3, 4, 4. Take the one in the middle. It’s a 99214. Hopefully you got this as well.
If this was a new patient, would the code be any different? Why? So again, a level 3
history, expanded problem focused exam so a level 2, and moderate complexity medical
decision making. For this new patient unfortunately this would be coded as 99202.
Hopefully you get the picture that this always isn’t a one for one swap and that’s the
difference.
So here is my last slide. The caption is “well you can’t say I never gave you anything.”
So hopefully I gave you a lot of coding information today that is useful to you. We are
going to open up the lines for some questions.
Moderator:
Great. Thank you so much Lissa for the great presentation. Timing was impeccable. Okay we
will start with a question in the chat room. If a non-licensed staff person operating under a
standing order, does the testing, counseling, etc. -- Will they still be able to bill if a provider is
not on site?
Lissa Singer:
The answer I would say is probably yes to that. The reason I can’t say yes 100% all around is
because you need to find out what your states Medicaid rules are if the patient is a Medicaid
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Speaker: Lissa Singer
8/7/2013
patient. Commercial insurance might be a little bit more persnickety about that in wanting the
billing provider on site. But I would say most Medicaid’s that I have worked with across the
country have some provision for that because they have realized that there are a lot of clinics that
are unmanned and not always a PA or nurse practitioner available. So I would say probably yes.
But to get a definitive answer I would say you need to figure out what your medicaid state rules
are.
Moderator:
Ok great. Many questions are if the slide and presentation will be available afterwards. The hand
out and the slide as a pdf will be posted to the billing tools. STDtac.org and the handout is already
there, the slides are being posted as we speak, and the recording of the webinar, where you can
view and listen at the same time, will be posted there as well it just may take us a little bit more
time to get up.
Okay another questions. Can you tell us what differentiates a new patient versus an established
patient? As we take care of individuals and they access us for episodic care. At an STD/STI
clinic they are often seeking episodic care, so how would you differentiate then a new from an
established?
Lissa Singer:
Well, I think there are two parts to this question or answer and that is – again I will go back to
that definition. If you ever want to access that it is at the bottom of the hand out. So a new patient
is someone that you or your colleague has not seen in three years. So I know that they come for
episodic care so the second part of that question is whether or not it could be an established
problem or an established patient with a new problem. If you have never seen that problem before
the problem is new the patient may not be new. So if you or your colleagues have not seen that
patient in three years it’s a new patient or one that they have never ever seen. But unfortunately if
one of your colleagues sees the patient and treats them for episodic care – say two or three
months ago – and you see the patient – even though you have never laid eyes on them – they still
are going to be an established patient for you because someone in your clinic saw them.
Moderator:
Okay, thank you. Patricia C. do you have a question?
Patricia C.:
I just wanted to ask about the high intensity counseling GO 445 and what the speaker could tell us
about this?
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Lissa Singer:
GO 445 is a HCPCS common procedural code -so it’s not a CPT code as such. Generally those
codes are used for Medicare patients only. Some Medicaid may reimburse them. So I don’t know
I don’t have HCPCS code in front of me but if I could get back to you on that – I will post the
answer when I get my code book in front of me.
Moderator:
Another question in the chat is would you use preventive codes for an STD office visit?
Lissa Singer:
Yes, there are some codes that you could use and they 99401-99405 and they are for counseling
visit for “preventive visits.” They are for counseling of preventive only, they are based on time.
We did not have time to include them. Remember these are prevention only and the patient can’t
already have a diagnosis of CT/GC or anything like that. The 99401 is 15 min and I believe it
goes up from there. We can post those codes for reference as well.
Moderator:
Thank you. Question: What is an Allied Health professional?
Lissa Singer:
Ah, an allied health professional is a PA/MP or midwife. That is new terminology, they don’t
like to call them mid-level providers. So the new terminology for Medicare and Medicaid is
Allied Health Professional. Sorry that I didn’t clarify that sooner.
Moderator:
Great thank you: Another question. Can RN bill for new STD visit – we were told that RN’s
cannot bill for new patients?
Lissa Singer:
Right. That’s the whole 99211 because that’s for an established patient. But again I will tell you
to contact your Medicaid state regulations because they may have a provision for you. In MA
they have loosened the rules for that. That is just in NE --they have realized that some clinic –
they want people to be treat – it’s a lot more costly for them that they don’t get treated. They may
have provisions for you to be able to see new patients. But as the definition stands a 99211 can be
billed by a RN so that’s the only one that can be billed by someone who is not an Allied Health
Professional.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Moderator:
Okay great. Follow up questions. What about RN’s that’s trained as STD clinicians. But I believe
that regardless of the training, if there isn’t a new certification –
Lissa Singer:
Right – if your not PA/ nurse practitioner or midwife even with the additional training which is
great that you have that - CPT doesn’t recognize that yet.
Moderator:
But they can bill for the 99211 for an established patient.
Lissa Singer:
Right.
Moderator:
Another questions. Can you tell us a little bit more about billing for an administering medication
and or drawing lab?
Lissa Signer:
Sure, there are some codes for drawing labs. I would refer you to your CPT code book. I used to
have it memorized and I want to say it’s a 99—something 4 -- for labs. But at any rate you can
bill for obtaining labs, you can bill for IM administration that code is in you CPT code book.
Sorry. We cannot cover every code in an hour. But if you are giving injections either vaccinations
or inter-muscular injections for antibiotics there are two different codes – one for vaccination one
for intramuscular injection and don’t forget you can also bill for the supply of the medication. If
you are paying for your vaccinations definitely you want to bill for them. If you are getting them
from your state for free then you can’t bill. If you are paying for your antibiotics you want to code
for your antibiotics as well using those J-codes. And there are more vaccinations for J-codes as
well that I could not include in this 1 hours presentation.
Moderator:
Another follow-up comment related to the HCPCS high intensity behavior counseling – which is- she did the follow up and says “I believe those preventive medicine codes 99401-99404 are
what are recommended for coding for high intensity behavior counseling.”
Lissa Singer:
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Right and I would agree with that because the G codes are funny. Not every payer pays for the G
codes but everyone seems to recognize the CPT codes which are the 99401-99405 which are
based on time which are a lot easier to do and to document for.
Moderator:
Excellent. Great. Thank you. Is there a resource that maps the STD IDC-9 to ICD-10 codes.
Lissa Singer:
There will be one available. I can get that resource for you. I believe there is mapping available
now.
Moderator:
I would look to the STDtac.org website under billing tools. We will get all the tools that have
been asked for – we will post them all to that website under billing tools.
Lissa Singer:
But just a caveat to that. Don’t think it is going to be specific to STI’s. It will be in the infectious
disease section that you would find all of those. But what I would be able to find for you is just
the general mapping IDC-9 to IDC-10.
Moderator:
A questions here -- should reference labs use special screening V codes for STD testing
performed if the provider has not specified IDC-9 codes?
Lissa Singer:
Well -- my experience has been is that the lab should not be using a screening code without
asking the clinic. So if the provider doesn’t provide the ICD-9 code hopefully that lab is calling
and asking you why you are doing this. They have no business just applying a screening code
when they don’t know for sure it’s a general screening or if there is a sign and symptom involved.
So my answer would be is if the lab is doing that I would question that because they don’t have
any prevue to just assign a screening code when they don’t have any other option. They should be
contacting you.
Moderator:
Another question – we are a small organization, would it be your opinion to have a special billing
coding person to handle this work? Or would you recommend our front line or clinic staff to do
this?
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Lissa Singer:
If you are a small clinic it’s a big endeavor. It’s a big endeavor that you might want to outsource
that. There are a lot of different payers and a lot of different rules and it’s not an easy job. So if
you’re not doing a lot of coding and billing it might be easier to outsource that.
Moderator:
And there a lot of organizations that do this that you can make a contract with.
Lissa Singer:
There are billing companies everywhere – I used to work for one.
Moderator:
Another question is could you please explain the 2 of 3 rule again?
Lissa Singer:
Sure. The 2 of 3 rule only applies to established patients. The 2 of 3 rule just means that once
you have coded each component score and you put them in order you just the component score
that is in the middle. So for instance if you have this available to you and it’s also in the slides if
you don’t have the hand out it is difficult to walk you through this. But an expanded problem
focused history would be a level 3 history. If you had a problem focused exam, that’s a level 2
exam. And if you had moderate complexity medical decision making that’s level 4 medical
decision making. So as I said put them in numerical order. You have a 2, 3, and 4. You take the
one that’s in the middle and that’s a 99213. Hopefully that’s clear.
Moderator:
Great. Someone else is asking where to get the pricing for the procedures.
Lissa Singer:
Now, for Medicare you can look it up on the website – what Medicare pays for every single
code. Commercial payers keep that a secret. For Medicaid some states also post their
reimbursement. The reimbursements that I showed you are just examples – they are ranges of
what you might see. But I have to refer you back again to either the Medicare website to get a
general idea of what the reimbursement in your area is. Commercial payers very difficult to find
out until you actually submit it and they tell you what they are going to pay for it. And Medicaid
some states do post their reimbursement rates on their website. And they can vary from
pediatrician to family planning clinic to STI clinics so beware of that when looking at your states
Medicaid reimbursements.
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
Moderator:
Great thank you. We have a question. When would you bill for a V01.6?
Lissa Singer:
Contact with or exposure to venereal diseases code – so that’s your diagnosis code. So when a
patients comes in and says “hey, my partner just got diagnosed” and they don’t have any signs
and symptoms yet – I would use that VO1.6. It’s a lot easier when they come in with a drip or
whatever – but a VO1.6 is contact with or exposure to venereal disease so that is when you know
your partner is positive and you come in to get treated.
Moderator:
Great. Thank you. We have another follow up question around the issue of billing for meds. If the
Meds have come from the state so if they have been given as an in-kind from the state, for
instance the state STD department – billing is not allowed? Correct?
Lissa Singer:
That’s correct. If you are getting your medications for free your vaccinations, or IM, antibiotics or
anything that you would give IM or anything like that even medications by now. If you are
getting them from the state for free you cannot bill for them because there was no out of pocket
cost for you.
Moderator:
There is a follow up questions with regards to 340B pricing. And the question is can those not be
billed for either?
Lissa Singer:
No, they are not in the same category. The 340B is just that you got a discount. Yes, so those can
certainly be billed for. Generally when you use a J-code for a supplies the payer is going to ask
for an MBC number – so you need to have that available and that all comes on the packaging. But
I believe that only provides you with a discount.
Moderator:
So there are two other questions which are related. They are asking for clarification and more
information about the 99211. How would we and could we bill for patients that come in for HIV
testing and counseling only? How would we bill for screening a patient visit if they only submit a
urine sample or an STD screen, for instance? The other question which is very much related is
JSI RESEARCH AND TRAINNING INST
Speaker: Lissa Singer
8/7/2013
some STD clinics are only staffed only with RN’s operating under an MD’s order. Did you say
that depending on the states rules they may be able to bill or in that incorrect?
Lissa Singer:
No, I didn’t say that. They may be able to bill but only would still be a 99211. The other
examples that you gave in the part 1 of that are all perfect examples of 99211 visits. So patient
comes in and they want some HIV counseling and an RN does that visit – umm again you need to
know what your states Medicaid rules are. Can it be a new patient with a new problem? Because
like I said they are willing to let that go and use a 99211 for a new patient and a new problem. So
I will refer you back to your state because that is where most of your patients are going to come
from – state Medicaid. But those are all great examples. Anything that can be done by RN under
the MD’s orders – but it would still only be a 99211 visit.
Moderator:
Another follow up question related. If a 99211 is billed for RN services, whose NPI number is
used on the claim?
Lissa Singer:
Right, so that would either be – it depends on what you decide to do. Again, back to that incident
to billing. If your billing lender, medical director or a physician it would be his NPI number. If
each nurse practitioner or PA are individually credentialed, they you could use whoever is on call
for that date. Because remember I said some state Medicaids say that your billing provider
doesn’t have to be physically present in the office building, but whoever that is that is available
within 15 min. or available for emergencies or available on the phone depending on what your
state Medicaid says would be the billing provider and you would use their NPI number:
Moderator:
I am afraid we are going to have to wrap up now--but great questions. Thank you everyone for
jointing us today and thank you Lissa for a great presentation and clarifying some tough
questions. Keep in mind this presentation was recorded and will be available on the website as
well as some additional resources. Its stdtac.org for future reference. We will send a link to a
survey money evaluation – it may actually be in your inbox already. We really appreciate you
taking just a couple minutes just to fill this out as it helps us to improve our training and improve
future training. Thank you again for joining us today.