Low Hanging Fruit and
Sleeping Well After Picking It!
Pediatric Topics in
Coding, Documentation, and Payment
Jonathan Shook, MD, FAAP
April 25, 2014
Disclosures
• Blue Cross & Blue Shield of Mississippi
• Pediatric Advisory Committee
• UnitedHealthcare Community Plan of Mississippi
• Provider Advisory Committee
• Coding info changes over time!
• Thanks to my partners and managers!
2014 AAP Annual Leadership Forum (ALF)
Adopted Resolution
• Reimbursement
•$$ Payment $$
Why is coding/documentation
important for Pediatricians?
• To optimize revenue for sustainability & growth.
• Most of us paid in some form based on production.
• We are cognitive specialists.
• Most services based on E/M codes.
• Lower RVUs.
• Questioned more by payers (vs. procedures).
Why is coding/documentation
important for Pediatricians?
• Coding rules are always changing!
• We tend to……
•
•
•
•
use only a few codes.
code at lower levels.
not code for procedures.
undervalue the worth of pediatric services.
Issues with E&M coding for doctors
• Minimal training.
• Rules are dated; made for adult medicine and paper charts.
• Dependent on others yet ultimately responsible.
• Not intuitive.
• “Play the game.”
Problems with current
“Fee for Service” payment model
• Volume-based
• “How many can you see in a day?”
• Unit driven
• Rapid strep on every sore throat?
• “Hamster wheel” effect
• No regard for quality, cost efficiency, or patient satisfaction.
How then shall we code?
Shall we learn minimally about coding and
reflexively code every patient the same and
focus on maximizing volume and units?
How then shall we code?
• Admit that an ideal workflow and optimal care
will not maximize charges/production.
• Learn the existing coding system and apply it to
our daily work to capture all appropriate
payment!
Why do coding/documentation matter?
Example Day #1: 25 pts
• 25 Level 3 est. visits (99213)
• 25 x $75.82=
$1,895
Example Day#2: 23 pts
• 18 Level 3 est. visits (99213)
• 5 Level 4 est. visits (99214)
• 18 x $75.82 + 5 x $113.91=
$1,934
• Saw 2 fewer patients but more
payment!
Medicaid
Primary Care Pay Increase (PCPI)
• Mississippi Medicaid insures ~ 340,000 children, or
about 45% of kids in Mississippi.
• CHIP ~ 70,000 or 9%
• ACA mandates Medicaid payment rates be raised to
at least Medicare rates for primary care and
immunization services for eligible providers in 2013
and 2014 with federal funds.
• DOM started 7/1/13; MSCAN coming soon
Primary Care Pay Increase
(PCPI)
• New Mississippi Medicaid Technical Bill secures the
pay increase until at least 2016 in Mississippi!
• Mississippi Division of Medicaid has committed to
maintaining this rate beyond 2016.
Payments for
Established Problem Visits
CPT
Private Avg
(5 MS payers)
MS Medicaid
MS Medicaid
With PCPI
99213
$75.82
$60.51
$69.62
99214
$113.91
$89.10
$102.58
99215
$153.38
$119.58
$137.96
Payments for
Established Well Visits
CPT
(Age)
Private Avg
(5 MS payers)
MS Medicaid
MS Medicaid
With PCPI
99391
(0-1)
$91.35
$61.58
$94.98
99392
(1-4)
$100.69
$69.19
$101.33
99393
(5-11)
$100.16
$68.54
$101.01
99394
(12 and up)
$109.49
$76.15
$110.76
Payments for
Vaccine Administration
CPT
Private Avg
(5 MS payers)
MS Medicaid
MS Medicaid
With PCPI
90460
$28.53
$10
$19.79
90461
$14.70
$0
$0
90471
$28.43
$10
$24.29
90472
$14.93
$10
$12.04
90473
$26.05
$10
$24.29
90474
$13.77
$10
$12.04
Impact of Medicaid Pay Increase
All well visit payments + vaccine admin fees in first 2 years of life.
Total: 0-2yrs
Private Avg
(5 MS payers)
MS Medicaid
MS Medicaid
With PCPI
$1,635.01
$784.66
(48% of private)
$1,276.02
(78% of private)
Other Medicaid Opportunities
Oral health assessment and fluoride varnish application:
• Can be billed twice per fiscal year, at least 5 months
apart, for patients under 3.
• D0145: oral evaluation & counseling = $33.04
• D1206: fluoride varnish application = $22.42
• Fluoride cost is less than $2 per dose.
Other Medicaid Opportunities
Perinatal High Risk Management/Infant Services System
(PHRM/ISS)
• T1023 can be billed twice in first year of life.
• $17.95
Well Visits
• 29% of all visits for children 0-21.
• 52% of all visits for infants.
• Most should involve immunizations.
• Achieving Bright Futures
• http://brightfutures.aap.org/
• New resource with coding documents for all well child
visits!
Well visit extras!
96110: Standardized developmental screening
• Average payment of 5 Mississippi payers = $15.65.
• Bright Futures calls for developmental screening at 9, 18, and 30
(or 24) months.
• Bright Futures calls for autism specific screening at 18 and 24
months.
• Can be used when a screen is done at a problem visit for a related
concern.
Developmental Testing 96110
Examples
• Ages and Stages Questionnaire (ASQ)
• Parents’ Evaluation of Developmental Status (PEDS)
• Vanderbilt Assessment Scales
• Modified Checklist for Autism in Toddlers (MCHAT)
• NOT direct observation or general checklist of milestones
for age (surveillance)
Developmental Testing 96110
• Performed or scored by nurse or other trained personnel.
• Parent/guardian report of behavior.
• Modifier -25 may be attached to associated E/M visit.
• Document interpretation in E/M visit note.
• Example: “Ages and Stages results were normal (or insert
abnormal). Reviewed and discussed.”
E/M Basics
• Driving factor should be “medical necessity.”
• Notes are for auditors among others.
New vs. Established Patients
We are not the same!
• Seen by the physician or another physician of the same
specialty in the same group practice within the past 3
years?
• No = New
• Yes = Established
•BIG differences in required documentation.
New vs. Established Patients
We are not the same!
• New visits, along with admissions, consults, and ER
visits, require all 3 factors.
• Established visits, along with subsequent hospital care,
require 2 of 3 factors.
• New visits are paid at higher rates.
E/M Basics
• Encounters consist of 3 components called “key factors.”
• History
• Physical Exam
• Medical Decision Making (MDM)
• Time as a “key factor” overrides all other key factors.
Coding Based on Time
• Time can be used as the key factor when:
counseling constitutes more than 50% of
the visit with the patient/parents.
• History, PE, and MDM are not required.
• Patient may not even be present!
Coding Based on Time
• Total time must be face-to-face time (in office) or floor
time (in hospital).
• Document total time face-to-face and time spent in
counseling/coordination of care (number of minutes for
both).
• Must document what was discussed with the counseling.
Coding Based on Time
Face-to-face time for New Visits and Est. Visits:
99201: 10 min
99202: 20 min (15)
99212: 10 min
99203: 30 min (25)
99213: 15 min (13)
99204: 45 min (38)
99214: 25 min (20)
99205: 60 min (53)
99215: 40 min (33)
“Oh, by the way…”
Well and problem visits on same day
• Preventive Care Codes (99381-99397) do not have the
same key factors as other E&M codes.
• Comprehensive and reflect an age and gender appropriate
history/exam.
• No chief complaint, no HPI.
• What about the patient’s concerns or problems?
“Oh, by the way…”
Well and problem visits on same day
• If an abnormality or problem is addressed in the
process of performing this service, and it is
significant enough to require additional work, code
an office visit also!
• Different diagnosis than the preventive medicine services.
• Use a -25 modifier with the office visit (for most payers).
Billing same-day well and problem visits
• Separate and Significant? Some considerations:
• Would have required return visit?
• Requires prescription management?
• Supported by separated diagnosis?
• If using time as a key factor:
• Document total time for well child visit and total time for the
“problem” visit.
• Have a separate note indicating the length of time spent in
counseling/coordinating care and what was discussed.
Billing same-day well and problem visits
• Issues:
• Might generate a co-pay.
• Careful consideration of E/M level.
• Some elements of E/M visit repeated in well visit.
• Some (one!) payers not paying YET.
• Need 2 separate notes.
• Can be separate documents or separated by a line or
paragraph in the same document.
Same-day well and problem visits
• Well visit note:
• History for well visit, but no HPI for problem as it isn’t
pertinent to health maintenance visit.
• Well Physical Exam: can include abnormal findings here or
document “refer to problem visit exam.”
• 1st note impression: Well Child.
• Plan: anticipatory guidance, vaccines, etc.
• Problem visit note:
• HPI for problem, pertinent ROS.
• Exam for system of complaint/problem, or “refer to well visit
exam.”
• Impression and plan for problem.
History
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past Medical, Family, and Social History (PMFSH)
Chief Complaint and HPI
• Office visits, consults, hospital admissions, and ER visits
must have CC.
• Preventive care should not have CC.
• HPI must be obtained and documented by the physician.
History of Present Illness
• Location
• Quality
• Severity
• Modifying
factors
• Timing
• Duration
• Context
• Associated s/s
Review of Systems
• Most common lack of documentation.
• Comprehensive history = “all other systems reviewed
and remainder of systems were negative.”
• NOT: “review of systems is negative.”
Review of Systems
(14 systems)
•
•
•
•
•
•
•
Allergic/Immunologic
Cardiovascular
Constitutional
Eyes
Ears, nose, mouth
Endocrine
GI
•
•
•
•
•
•
•
Hematologic/lymph
Integumentary
Musculoskeletal
Neurological
Psychiatric
Respiratory
GU
ROS and PMFSH
• Can be obtained by staff or parents
• Interval history (for ROS and PMFSH)
• Example: “PMFSH obtained on 1/23/14 and reviewed today.
No changes are noted.”
• Unobtainable History
• Document: “Due to acute critical illness or language barrier,
ROS and PMFSH unobtainable.”
• Qualifies for comprehensive history.
4 types of history
• Problem-focused: (99212, 99201)
• 1-3 HPI
• Expanded problem-focused: (99213, 99202)
• 1-3 HPI, 1 ROS
• Detailed: (99214, 99203)
• 4+ HPI, 2-9 ROS, 1 PMSFH
• Comprehensive: (99215, 99204, and 99205)
• 4+ HPI, 10+ ROS (or some with statement “remainder of
systems negative”), and 2 PMSFH for est., 3 PMSFH for new,
consults, etc.
Physical Exam
• Can use either 95 or 97 guidelines:
• 97 are more for subspecialty practices and involve counting
bullet items.
• 95 are “more forgiving” and more easily justified in
Pediatrics.
• Remember “medical necessity.”
• Cannot code higher just because we did more during exam if it
was not warranted.
4 Types of Physical Exam
• Problem focused: (99212, 99201)
• 1 organ system
• Expanded Problem focused: (99213, 99202)
• 2-7 brief organ systems
• Detailed: (99214, 99203)
• 2-7 brief organ systems with extended exam of affected
system
• Comprehensive: (99215, 99204 and 99205)
• 8+ brief organ systems
Physical Exam
(12 systems)
•
•
•
•
•
•
Constitutional
Cardiovascular
Ears, Nose, Mouth
Eyes
GI
GU
•
•
•
•
•
•
Hematological/lymph
Integumentary
Musculoskeletal
Neurological
Psychiatric
Respiratory
Medical Decision Making
• Most subjective area of “leveling” of care.
• Composed of 3 factors! (surprise)
• Risk of complications.
• Number of diagnoses.
• Amount or complexity of data to be reviewed.
• Use highest 2 of the 3 categories.
• If these 2 levels are different, then use the lower of the 2 for
MDM determination.
Medical Decision Making
Type of MDM
Risk of
comp.
Numb. of
Diagnoses
Amt./comp.
of Data
Straight-forward Minimal
99212, 99201 &
99202
Minimal (1 pt)
Minimal (0
or 1pt)
Low complexity
99213, 99203
Limited (2 pt)
Limited
(2 pt)
Low
Moderate comp. Moderate Moderate (3 pt) Moderate
99214, 99204
(3 pt)
High complexity High
99215, 99205
Extensive (4 pt) Extensive
(4 pt)
Risk of Complications
Level of Risk
Presenting Problems
Diagnostic procedures
Management options
Minimal
1 self limited or minor
Lab test- venipunc
Bandage/rest
Low
-2+ self limited
-1 stable chronic illness
-Acute uncomplicated
Illness or injury
-Superficial needle bx
-Lab test- art. punc
-imaging w/ contrast
-Physiologic tests
-OTC drugs
-Minor surgery
-OT/PT
-IV fluids
Moderate
-1+ chronic illness with mild
exacerbation
-2+ stable chronic prob.
-Acute illness with systemic
symptoms
-Acute complicated injury
-Undiagnosed new prob.
with uncertain prog.
-Multiple x-rays
-Deep needle bx
-LP, joint asp.
-CT, MRI
-Cardio imaging
-Phys. tests w/ stress
-endoscopy
-Minor surgery with
risks
-Elective major
surgery
-Prescription drugs
-Closed Tx of Fx
High
-1+ chronic with severe
exacerbation
-Injury or illness with threat
to life/limb/bodily function
-Abrupt change in neuro
status
-Discography
-Myelography
-Arthrogram
-Cardio imaging or
endoscopy with risk
factors
-Elective major
surgery with risks
-Emerg. major surgery
-Parental control. sub.
-Drug Tx w/ int. mon.
-DNR or withdrawal
Number of diagnoses
1 pt
1 pt
Self-limited or minor problem (stable, improved or
worsening)
Est. problem (to examiner); stable, improved
2 pt
3 pt
Est. problem (to examiner); worsening
New problem (to examiner); no additional workup
planned
4 pt
New problem (to examiner); additional workup planned
Amount and/or complexity of
data reviewed
1 pt
1 pt
1 pt
1 pt
Review or order of clinical lab tests
Review or order of radiology tests
Review or order other tests (EKG, PFT, etc.)
Decision to obtain old records and/or obtain history
from someone other than patient
2 pt Review and summarization of old records
2 pt Discussion of case with another health care provider
2 pt Independent visualization of image, tracing, or
specimen itself (not simply review of report)
Medical Decision Making
Type of MDM
Risk of
comp.
Numb. of
Diagnoses
Amt./comp.
of Data
Straight-forward Minimal
99212, 99201 &
99202
Minimal (1 pt)
Minimal (0
or 1pt)
Low complexity
99213, 99203
Limited (2 pt)
Limited
(2 pt)
Low
Moderate comp. Moderate Moderate (3 pt) Moderate
99214, 99204
(3 pt)
High complexity High
99215, 99205
Extensive (4 pt) Extensive
(4 pt)
Improving Coding/Documentation
• AAP.ORG - Professional Resources/Practice Support
• Achieving Bright Futures
• AAP Pediatric Coding Newsletter
• Coding for Pediatrics
• CME events
• Ensure at least one physician and one office staff member
are coding/documentation champions!
Questions?
jshook12@yahoo.com