Coding and Billing in the ICD-10 Era
Daniel A. Ostrovsky, MD FAAP FACP
Chief Coding Consultant Duke Pediatrics
Assistant Professor, Internal Medicine Pediatrics
Duke University Medical Center
Objectives


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Understand what an ICD-10 Code and
CPT code are.
Understand how to appropriately
choose Evaluation and Management
codes
Understand how to appropriately
document for chosen E&M codes
What We Know



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Providers tend to underestimate the
services they provide.
Provider education on the “Business”
of medicine is poor.
Fear of auditing leads to under coding.
Ambiguous guidelines lead to
significant variance in how providers
code for services.
ICD-10

Designed to increase specificity of disease
characterization and better characterize illness severity

Better codified data means
– More accurate identification of patients for research
– More accurate characterization of provider case mix index
– More accurate characterization of patient severity of illness
– Better reimbursement and fewer claims denials
ICD-9 vs. ICD-10
Anatomy of an ICD-10 Code
What does this mean for
you?
Most providers currently use a relatively small
code set of diagnoses regularly (approximately
For
most, selecting appropriate codes won’t seem
20-50)
very different!
 For many codes in ICD-9 there is a single
matching code in ICD-10.
 The biggest expansion of codes are in surgical
or procedural specialties where site, location,
laterality, and phase of care lead to lots of
possible combinations.

Reminders for Documentation

ICD-10 specificity requires documentation of the
following whenever possible/relevant
–
–
–
–
–
Acuity (acute or chronic)
Site Specificity (anatomic location)
Laterality (right, left, bilateral)
Timing of Care (initial, subsequent, sequela)
Manifestations ( “due to”- secondary manifestations of or
external cause of a primary disease or injury)
– Staging (eg. CKD stage II)
– Status (History/Resolved/Remission)
– Type (eg. DM II, bacterial/viral, simple/complex)
ICD-10 “Extras”

“Additional” Codes
– Coding for tobacco exposure in most chronic
respiratory conditions.
– Coding for insulin usage in Type II DM
– Coding external causes of injury

“Combination” Codes
– Eg. Mild intermittent asthma with exacerbation as
opposed to mild intermittent asthma + wheezing
– Type II DM with diabetic nephropathy, etc..
– Allergic rhinitis due to pollen
Guidance for Code Selection


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In many cases, your documentation may be more
specific than an available ICD-10 code. Choose
the most specific!
Don’t select “unspecified” options unless they are
truly clinically unknown
Pick age and sex appropriate codes
Code all documented conditions that coexist at
the time of the encounter/visit, and require or
affect patient care treatment or management.
Make sure those specific codes appear in your
documentation
Coding Uncertain Diagnoses
Professional Coding

Do not code diagnoses documented as
“probable”, “suspected,” “questionable,” “rule
out,” or “working diagnosis” or other similar
terms indicating uncertainty. Rather, code the
condition(s) to the highest degree of certainty
for that encounter/visit, such as symptoms,
signs, abnormal test results, or other reason
for the visit.
Hospital Coding

If the diagnosis documented at the time of discharge is
qualified as “probable”, “suspected”, “likely”,
“questionable”, “possible”, or “still to be ruled out” or
other similar terms indicating uncertainty, code the
condition as if it existed or was established.

Abnormal findings (laboratory, x-ray, pathologic, and
other diagnostic results) are not coded and reported
unless the provider indicates their clinical significance.
Make sure these are part of your clinical
documentation!
Just like before…


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You should be DOCUMENTING as specifically
as possible including relevant clinical detail
Code the diagnoses you are managing and
change/modify them as appropriate
Keep problem lists updated
Use appropriate codes that are age and sex
appropriate
Have documentation that supports the selected
codes
So what’s changed???



Now insurance companies have more specific
diagnoses to decide whether to pay or deny
your claim!
Value Based Care is knocking at the door and
failure to document and code thoroughly and
specifically will have multiple downstream
ramifications
EMR’s have been a double-edged sword
– Pulls data quickly together but is the data accurate?
– Allows efficiency shortcuts but are they accurate?
We all have to do our part!
Excellent FREE Resources

ICD-10 lookup by code or text word

– http://www.icd10data.com/
CMS ICD-10 Pediatrics Resource Page
– http://www.roadto10.org/example-practice-pediatrics/

ICD 10 Consult 2016 Free (Free App for mobile devices
by Evan Schoenberg)
Level of Service Coding/Billing
Advanced Practice Providers
– When Billing for Services

Bill independently
– The Supervising MD does not need to be in the office suite

Bill in the supervising providers number when “sharing”
the visit with the provider
– only allowed for inpatient, hospital based clinic, or ED settings
Very Important – Procedures, Critical Care, Consultations cannot be
billed as shared. The APP must bill in his/her name if s/he is performing
the procedure.
Shared Visit
Applies only to Inpatient, hospital based clinic, or ED

When an APP and their supervising physician share a visit together, the
service can be billed in either the APP’s number or the supervising
physician’s number. The following are the guidelines to follow when billing a
shared visit:

A shared visit is a medically-necessary encounter with a patient where a
physician and a qualified APP each perform and document a substantive
portion of the evaluation and management visit, face-to-face with the same
patient on the same date of service.

Each provider, the MD/DO and APP, would perform parts of the service and
personally document their parts.
– One cannot document for the other.
– Each provider’s documentation should be separate and patient specific.

Resident/Fellows cannot share visits with APP’s
CPT




Current Procedural Terminology
Standardized codes used for billing
Codes available for every type of
service provided
Linked to ICD codes to justify services
provided.
Evaluation and Management
Coding Elements

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
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History
Physical Exam
Medical Decision Making
Face to Face Time
Guidelines developed by CMS (Centers
for Medicare and Medicaid Services)
Medical Decision Making



Presenting problems
 Number and complexity
Data
 Type of tests
 How they are reviewed
Risk
 Multidimensional assessment
Problem Points
Eg. Bug bite, simple strain/sprain
Eg. Asthma, ADHD, Eczema
Eg. Asthma, Eczema
Eg. AOM, SOB, Dizziness
Eg. Headache, abdominal pain
Add up the points to get a total. For example, a child being seen for an
exacerbation of their asthma who also has allergic rhinitis which is well controlled on
current therapy would garner 2 points for the asthma with exacerbation and 1 point
for the allergic rhinitis giving a problem point total of 3.
Data Points
•You only get 1 point for ordering/reviewing multiple lab tests
•You must document your personal read of an image, tracing, or
specimen to get the points for an independent review
Risk

Four levels
– Minimal 99212
– Low 99213
– Moderate 99214
– High 99215

Three Dimensions
– Presenting Problems
– Management Options
– Diagnostic Procedures
Choose
the
highest
level of
risk!!!
Medical Decision Making
Putting it All Together
99212
99213
99214
99215
Two out of three factors must meet or exceed
the requirements for any given level of
medical decision making.
“The Table”
History
Exam
MDM
Face-to-face
$$
99211
Supervision Only
Supervision Only
Straightforward
5 minutes
$16.82
99212
HPI: 1-3 elements
“Problem Focused”
1 system
“Problem Focused”
Straightforward
10 minutes
$33.50
99213
HPI:1-3 elements
ROS: 1system
“Expanded”
2-7 systems
One element per
system
“Expanded”
Low
15 minutes
$55.94
99214
HPI: 4+ elements
ROS: 2-9 System
1/3 P/F/SHx
“Detailed”
2-7 systems
At least one of the
systems having at
least 2 elements
noted
“Detailed”
Moderate
25 minutes
$84.29
99215
HPI: 4+ elements
8+ systems
Single element from
each acceptable
“Comprehensive”
High
40 minutes
$114.00
Or
Status of 3 active or
inactive problems
ROS:10+ system
2/3 P/F/SHx
“Comprehensive”
Billing for Time Counseling



To be used when >50% of the visit is
spent in teaching/counseling the
patient in regard to the presenting
issue.
This is different then extended face to
face time.
Documentation Statement
– eg. For 99213

“I spent 15 minutes face to face with the
patient and family in which 10 minutes were
spent counseling the parents in supportive
care for URI and proper sleeping position.”
Inpatient Time Based Billing


Time spent must be ON THE PATIENT WARD
Time includes only the EXCLUSIVE time spent
in the management and care of the specific
patient
New
Established
Modifier 25

Used when a separate and identifiable
procedure is performed.
– Ex: Incision and Drainage of an abscess
– Administration of vaccines in a non-hospital based
clinic

Used for a “Split visit”
– Patient presents for a preventative visit but also has
an acute issue which you manage and clearly
document the separate issue.

Need to be linked to an appropriate ICD code.
Modifier 25
Examples

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I&D of Abscess 10060
$88
Joint Injection/aspiration 20600
$45
Wart Destruction 17110
$86
Removal of Cerumen impaction 69210 $40
Reduction Nursemaid’s elbow 24640 $93
Ganglion Cyst aspiration 20612
$48
Prolonged Services
– 1st hour 99354
– Each additional 30 minutes 99355
$85
$84
Preventive Service Visits

Well Child Checks have CPT codes based
on the age of the patient
– <1y
– 1-4 y
– 5-11y
– 12-17y
– 18-39y


Need to be linked to an appropriate ICD-10
code.
Z00.129 (Routine WCC without abnormal
findings)
You Code It!!!
(Time Permitting)

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Hx: 5 elements
ROS: At least 2 (GI, GU)
P/F/SHx: 3/3

Detailed problem focused (99214)

PE:
5 Systems
with at least 2 elements per system

Detailed problem focused (99214)

MDM:
Problems: New problem with no additional
w/u (3 points)=Moderate
Data Points: 0
Risk: Moderate- prescription drug
management
2/3 moderate or higher so moderate MDM
(99214)

Code: 99214
Could be based on just H&P but MDM
supports as well.
Split Visit
•URI documentation
yields 99213 linked
to acute upper
respiratory infection,
unspecified site
J06.9
Modifier 25
•4 yo WCC
•CPT 99392
linked to WCC
•Procedures
•Vision 99173
•Hearing 92551
•Developmental
Screen 96110



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Hx : 2 elements, ROS 2
systems
Expanded Problem
Focused (99213)
PE: 2 systems
Detailed Problem
Focused (99214)
MDM:
Problems: Established
problem stable or
improving (1 point)
Data: Reviewed Throat Cx
(1 point)
Risk: One self-limited
problem
Overall MDM minimal
(99212)

Code: 99212
2/3 meet requirements.

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Hx: 4 elements, PMHx,1 ROS
Expanded (99213)
PE: 2 organ systems with
single element in each
Expanded (99213)
MDM:
– Problem: 1 minor, selflimited problem (1 point)
– Data: 0
– Risk: Low (OTC med)
Overall MDM is straightforward
(99212)
Code: 99213
2/3 support the dx code chosen.


Hx:4+Elements, ROS 2+, PMHx, FHx
Detailed (99214)

PE: 5 systems
Detailed (99214)

MDM

–
–
–
Problem: New problem with planned
further workup (4 points)
Data Points: culture sent (1 Point)
Risk: Prescription drug management
(moderate)

Overall MDM: Moderate (99214)

Procedure: I&D

Code: 99214
Modifier 25 with
procedure 10060 linked
to cutaneous abscess of
buttock L02.31


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Hx: 4+Elements, ROS >10
PFSHx
Comprehensive (99215)

PE 8+ organ systems
Comprehensive (99215)

MDM

Moderate Persistent asthma
– Problem: Established
problem worsening (2
points) Low
– Data: Order CXR 1 point,
personal review 2 points. 1
point for Pulse ox Total=4
points High
– Risk: High
Moderate Persistent asthma with acute exacerbation- No clear source for exacerbation. Not
responding adequately to nebs here. Will require further management in ER for his severe sx.

Overall MDM=High (99215)

Procedure: nebs

Code: 99215 modifier 25
procedure 94640 linked to
Moderate persistent asthma
with exacerbation J45.41

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Hx: 4+ elements, 2+
ROS 2+, 2/3 PFSHx
Detailed (99214)
PE: 8+ systems
Comprehensive (99215)
MDM:
– Problem: New problem
without additional workup
planned (3 points)
– Data: UA/Ucx (1 point)
– Risk: Acute illness with
systemic sx. (moderate)

Overall MDM: Moderate
(99214)

Code: 99214 linked to
Fever, unspecified
R50.9


Hx: 4+ elements, ROS 3
systems, PM/SHx
Detailed (99214)

PE: 7 systems
Detailed (99214)

MDM:

– Problem severity: New
Problem, further workup
planned. 4points
– Data: UA/Ucx,1 point=
minimal
– Risk: Rx
management=moderate

Overall MDM=moderate
(99214)

Code: 99214
Hx and PE not suggestive of vaginitis or STD or other abdominal process.


Hx: 4 elements, 1 ROS,
PMHx
Expanded (99213)

PE: 2 Systems one with
2+ elements
Detailed (99214)

MDM:

– Problem: Established
Problem, worsening (2
points) (Low)
– Data:0
– Risk: Prescription Drug
Management=Moderate

Overall MDM=Low
(99213)

Code: 99213 linked
to allergic eczema
L20.84
Allergic


Hx: 4+ elements, 2+
ROS, P/SHx
Detailed (99214)

PE:8+systems
Comprehensive
(99215)

MDM

– Problem: New problem
with further workup (4
points) (High)
– Data: Flu PCR, 1 point
– Risk: Prescription drug
management
(Moderate)

Overall MDM:
Moderate (99214)

Code: 99214 linked
to cough R05


Hx: 4+ elements, 2+ ROS,
P/SHx
Detailed (99214)

PE: 7 systems
Detailed (99214)

MDM:

– Problem: New problem no
further workup (3 points)
– Data:0
– Risk: acute self-limited
problem=Low
– Overall MDM: Low (99213)

Code: 99214 linked to J06.9
Acute URI of unspecified site

2/3 support this code and the
nature of the problem
supports the extent of history
and PE.



Time Based Coding
30 min
Code: 99214 linked
to encounter for
pregnancy test,
result positive
Z32.01
Link to Dan’s Medical
Decision Making Calculator
(Proprietary for your personal use only)
Dan Ostrovsky’s Medical Decision Making Calculator (Excel)
https://www.dropbox.com/s/jvq6zlwj73qhw77/MDM%20
calculator%20final.xlsx?dl=0
SPECIAL THANKS
Tammy Clay, PDC Chief Compliance Officer
Jessica Ferrari, Pediatrics Revenue Manager
Danielle Graf, Pediatrics Revenue Manager
Melissa Sangster PDC Revenue Manager
References
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aappediatric coding newsletter. The AAP peer-reviewed coding and
Nomenclature Newsletter. 2009. Vol.4, Number 10. 2-12.
AAP Coding Calculator *subscription to coding newsletter required
AAP NC 2007/8 Medicaid Reimbursement Survey
Hearing Screening Coding Fact Sheet for Primary Care Pediatricians
http://emuniversity.com
Jensen PR. Coding Routine Office Visits:99213 or 99214. Family Practice
Management. 2005. September. 52-57.
Physicians Computer Company
www.icd10data.com
www.nctracks.nc.gov
http://www.roadto10.org/
http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf
ICD-10-CM The Complete Official Draft Code Set 2013.
www.optumcoding.com