Preventative care pays. 99401 and others

Did you know that you can get paid for doing the preventative care? You can.

In the CPT book it is called Counseling Risk Factor Reduction and Behavior Change Intervention.

This is a distinct set of codes from the traditional E and M services and can be billed IN addition to the E and M services you provide.

That means, no modifier 25.

The catch?

1. You have to document how much time you spend in preventative care. 99401 is 15 minutes of care.

2. You have to ICD9 code using a V code or a diagnosis code for the preventative care you are providing. Which means on Diagnosis Pointers on the HCFA form, you have to list a pointer.

3. You have to understand preventive medicine counseling and risk factor reduction interventions provided as a separate encounter will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health and diagnostic and laboratory test results available at the time of the encounter.

What does this mean? It means that you get paid for performing preventative care. Something you should be doing just about every appointment.

If you are looking on the AAPC listserv it seems that NO ONE is using these codes.

Why not? If you are providing primary preventative care.
i.e. Use condoms, buckle up, adjust water temp, lift with your legs, lose weight
Then you should get paid for these additional preventative services.

The breakdown-
99401 is for 15 minutes of preventative care
99402 is for 30 minutes of preventative care
99403 is for 45 minutes of preventative care
99404 is for 60 minutes of preventative care

So, document what you do and then go ahead and bill for these important code. Remember, an ounce of prevention is worth a pound of cure and some insurers pay that way.

"Face-to-Face" in outpatient E/M does not exclude video chat

Video chat medical consultations are coded as Evaluation and Management (E/M) "Office or Other Outpatient Services" (99201 to 99215) ---just like any other outpatient consultation, no special code needed.

So?

Video chat medical consultations can be provided to patients as a new service without changes to existing medical insurance billing practices. Video chat also has the benefit that it is recorded, replayed, and shared with perfect fidelity. Video does not replace physical consultation, but it does efficiently distribute and triage limited medical consultation resources worldwide while automatically documenting medical events electronically.

Why?

The E/M criteria for "office and other outpatient visits and office consultations" includes "face-to-face" patient interaction defined by the AMA as "time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining history, performing an examination, and counseling patients." ("CPT 2009" pg. 5) This constraint contrasts with the "unit / floor time" criteria used for E/M hospital coding, which by noting a physical location, is actually more constraining physically than outpatient CPT coding which does not specify any physical proximity ---only "face to face."

Clearly, video chat is "face-to-face." If it were not, then what is the purpose of the "video" in "video chat"?

However, outpatient E/M codes 99201 to 99215 do explicitly exclude "communicating further with other professionals and the patient through written reports and telephone contact." That is, voice and written communication without the "face-to-face" real-time visual contact ---the video--- does not qualify.

Objections

Because video chat is "electronic," some believe video chat should be coded as 99444. No! According the AMA definition for 99444, video chat cannot be coded as a 99444 because:

FAIL 1) "non-face-to-face" Video is face to face.

FAIL 2) "physician's personal timely response to the patient's inquiry" Video is face-to-face consultation, not a delayed response to recorded inquiry, as implied by "timely response"

FAIL 3) "this service is reported only once for the same episode of care during a seven-day period" 99444 is an asynchronous exchange of messages, as implied by "during a seven-day period. Video is synchronous, and each "event" is a uniquely submitted "episode of care."

99444 is clearly for web forum and email threads, not video (FAIL 1: face-to-face), not chat (FAIL 3: sync), and not voice (FAIL 2: immediate response, FAIL 3: sync).

Also, some believe that a physical examination is necessary to code outpatient E/M events. This is also a myth. The AMA CPT code book has no qualification explicitly requiring tactile examination to qualify "extent of examination." The only coding qualifications specified are:

- clinical judgment
- nature of presenting problem
- quantity of organ systems / body areas examined

Thus, the limiting qualification is the clinical necessity for physical contact, which is what it should be. If the patient needs to visit the office, the patient needs to visit the office. If not, then not. Not sufficiently examining as clinically indicated is already known as "not doing your job," and inflating a clinical note is already known as "lying." There's no need for a special qualification just because the doctor uses new, better tools.

But yes, in practice, video will probably be coded lower on average than physical examinations ---all else equal--- because the provider will be unable to physically interact with the patient. However, for many routine medical consults, physical interaction is clinically unnecessary unless specifically indicated otherwise.

Same Day Service Inpatient Observation is it a 99236?

Today I cared for a patient and performed a monitored test on them. I wondered what exactly I should code for this encounter. Then I turned to trust ol CPT 2009......

There are 3 codes for Observation admission and discharge of a patient in the same day. these are 99234, 99235 and 99236.

The inpatient and outpatient E and M codes all have the same format. New Patient? You must meet all 3 criteria. In this case it all admitted patients are considered new patients in house....

So these criteria are very similar to outpatient encounters.

The 99236 requires:

1. Comprehensive history
2. Comprehensive Examination
3. Medical decision Making of High Complexity

The Comprehensive history is:
1. A chief complaint
2. An extended HPI (four HPI elements OR the status of three chronic or inactive probs.
3. A 10 system ROS
4. A Complete PFSH. Which includes Meds, Allergies, FamHx, SrgHx, MedHx
Remember it only takes on element from each category of the PFSH to qualify as complete.

The Comprehensive Examination is 2 points from 9 organ systems. Are you telling me you forgot the systems?

FYE
Constitutional

1) Three vital signs
2) General appearance

Eyes

1) Inspection of conjunctivae and lids
2) Examination of pupils and irises (PERRLA)
3) Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

1) External appearance of the ears and nose (overall appearance, scars, lesions, masses)
2) Otoscopic examination of the external auditory canals and tympanic membranes
3) Assessment of hearing
4) Inspection of nasal mucosa, septum and turbinates
5) Inspection of lips, teeth and gums
6) Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx


Neck

1) Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
2) Examination of thyroid

Respiratory

1) Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
2) Percussion of chest (e.g., dullness, flatness, hyperresonance)
3) Palpation of chest (e.g., tactile fremitus)
4) Auscultation of the lungs

Cardiovascular

1) Palpation of the heart (location, size, thrills)
2) Auscultation of the heart with notation of abnormal sounds and murmurs
3) Assessment of lower extremities for edema and/or varicosities
4) Examination of the carotid arteries (e.g., pulse amplitude, bruits)
5) Examination of abdominal aorta (e.g., size, bruits)
6) Examination of the femoral arteries (e.g., pulse amplitude, bruits)
7) Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

1) Inspection of the breasts (e.g., symmetry, nipple discharge)
2) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen)

1) Examination of the abdomen with notation of presence of masses or tenderness
2) Examination of the liver and spleen
3) Examination for the presence or absence of hernias
4) Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,
rectal masses
5) Obtain stool for occult blood testing when indicated

Genitourinary (Male)

1) Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
2) Examination of the penis
1) Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

1) Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
2) Examination of the urethra (e.g., masses, tenderness, scarring)
3) Examination of the bladder (e.g., fullness, masses, tenderness)
4) Examination of the cervix (e.g., general appearance, discharge, lesions)
5) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
6) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes two or more areas:

1) Neck
2) Axillae
3) Groin
4) Other

Musculoskeletal

1) Examination of gait and station
2) Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six areas:

a) head and neck
b) spine, ribs, and pelvis
c) right upper extremity
d) left upper extremity
e) right lower extremity
f) left lower extremity

The examination of a given area may include:

1) Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,
2) defects, tenderness, masses or effusions
3) Assessment of range of motion with notation of any pain, crepitation or contracture
4) Assessment of stability with notation of any dislocation, subluxation, or laxity
5) Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements

Skin

1) Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
2) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

1) Test cranial nerves with notation of any deficits
2) Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
3) Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

1) Description of patient’s judgment and insight

Brief assessment of mental status which may include

1) orientation to time, place, and person
2) recent and remote memory
3) mood and affect

1997 Specialty Exams can be found here.

Lastly for all admitted patients you must ALSO meet the third criteria.....Medical Decision Making.....

MDM for short. In this case 99236 the medical decision making must be of high complexity. Which is ALWAYS a bear, unless you know how to do it.

MDM is judged by 3 criteria.

• Problem Points, 4 points required
  
• Data Points, 4 Points Requires
• Risk Chart, High Risk

Luckily, you only need 2 of 3 criteria to qualify for the Highest Level of MDM. Most people accomplish this feat through data and problem points....

Always hit the problem and the data points, Strive to hit risk….

You need Four Problem Points

New Problem with work up (4)
New problem no Work up (3)
Est Problem, Worsening (2)
Est Problem Stable(1)

Four Data Points
Labs(1) Ordered OR Reviewed
Indep Review of EKG/Film/Specimen (2)
Reviewed Old records (2)
Decision to Obtain Old Records (1)
Discuss test with Physician(1)
Order Test EKG/Cath/PFTs (1)

Risk, to be high risk
1 New Problem which poses a threat to life or limb
1 chronic illness with severe exacerbation
1 change in neurologic status

Or if you chose to do

1. Cardiovascular imaging, with contrast
2. Cardiac EP studies
3. Diagnostic endoscopies
4. Discography
5. Elective major surgery
6. Emergency major surgery
7. Parenteral controlled substances
8. Drug therapy requiring intensive monitoring for toxicity (Digoxin/Heparin)
9. Decision not to resuscitate, or to de-escalate care because of poor prognosis
Or the decision to do the following

Most of these things aren't done on an ambulatory basis, so you are essentially screwed with the risk part of this.

In other words, YOU CAN ONLY BILL 99236 IFF you meet the Problem AND Data points. IF you do not, you cannot likely make the grade for a 99236.

Want to learn more about coding? Email me at modifier25@gmail.com

99232 when your best isn't good enough!

Sometimes we have patients who just don't meet 99233 criteria for additional days in the hospital. I often find myself asking "Why not discharge them?" Inevitably it is for silly things like

1. Needs IV abx
2. Awaiting placement
3. Has a ride tomorrow
4. Getting therapeutic (Although if there is a PE involved, you go to the 99233 line)

In these cases I find it necessary to review why we missed the 99233 and why I need to code as a 99232.....

For your edification.......

a 99232 is a subsequent day of care in the hospital Which needs you to meet 2 of 3 criteria.
The best part about this coding system is that when you have already established care with the patient, the criteria for upper level codes is far less....

In this case the 2 of 3 are

1. Expanded Problem Focused interval history
2. An expanded Problem Focused examination
3. MDM of moderate complexity

To compare to the 99233 you can read it here.
So again with the sub-categorization of what expanded problem focused means....

Exanded Problem Focused History is:
A chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

Are you telling me you only do ONE ROS? And only one HPI element? If you do 3, you better do 4 elements. If you do one ROS, you really should do more........Why? It serves the patient better to look for things and think about the case. Too much of medicine is driven to mindless care......

Expanded Problem Focused Exam is:
6 bullet points from one or more system.
Heart and Lungs? Yup.....all done.....

Basically this is a gimme. Did you end up doing more than this? Then you should consider the 99233

Lastly you need to factor in Medical Decision Making.....and in this case it is of moderate complexity.....

What is Moderate Complexity? Remember, this category is judged by
1. Problem Points- I.E. what is the nature of the problem.
2. Data Points- I.E. what work did you review and cogitate over
3. Risk Level- I.E. risk to patient's life

Again, you only need 2 of 3 at the highest level

The risk is evaluated in a risk table presented best at EM University.

One chronic problem with mild exacerbation gives you moderate risk so do 2 stable controlled diseases i.e. hypertension and hyperlipidemia

So you can usually get 2 of 3 here pretty easily. But you should always ask yourself.......did I really do a 99233 instead of a 99232.....It is just good medicine.

Subsequent Hospital Days 99233 is a most often code.

Ok,
After a long time off, I am back with more coding catastrophes.......

Before going any further, I hope you are making checklists of the documentation requirements for each code. If you are not, then you could end up paying your EMR vendor tons of money so they and your coders can bilk your wallet.......

So let's begin......

Subsequent hospital care includes a review of interval changes since last time, so don't count on that as helping your MDM so much.......

But the good news is for subsequent care, just like for established patients, you only need 2 of 3 categories at the highest level to qualify your coding.....

Let's look at the highest and go down from there

99233 requires:
1. A detailed interval history
2. A detailed examination
3. Medical Decision Making of High Complexity......

Remember, you only need 2 of 3.

A detailed interval history is the next to highest level of history. Which means, you should at least be doing this all the time.....It includes
A. A Chief Complaint
B. An extended HPI: 4 points (Location, Severity, Timing, Modifying Factors, Associated Symptoms, Duration, Quality, Context) All you need is 4 of these.....OR the status of 3 chronic or inactive problems
C. 2-9 Review of Systems, don't we usually do 10?

The last requirement is dropped for subsequent hospital care.
Dropped a requirement? Seriously? Yes. But only for Subsequent Nursing facility care, Subsequent Inpatient care and Subsequent inpatient consultation......

So, it looks as if we can make the History requirement

Next Up, the physical exam

A Detailed Examination

This requires 12 bullets from ANY organ system. Or from multiple organ systems......
These include Vitals and General as 2 Bullets. So 10 bullets points.......You better know the systems by now!

You don't? First time here? Look at this post for the physical exam

Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)

Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)

Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)

Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)

Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)

Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)

Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)

Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)

Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)

Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)

Total systems = 10

If, examine heart, lungs, skin, abdomen you meet the grade. If you examine HEENT and heart and lungs, you make the grade as well.........

In essence, most of your subsequent care is 99233. What is a 99232?

But what if you didn't make both of those? You fall back on Medical decision making of high complexity.

You need 2 of 3 criteria to make the high complexity grade. As always, these are divided into:
A. Problem Points, you need 4
B. Data Points, again you need 4
C. Risk, you need high risk

The good news, you only need 2 of three. Also, the decision to make someone DNR or to use IV controlled substances qualifies you for high risk!!!

Here's to a morphine drip!!!

So think about it, really hard. Aren't most of your patients in this realm? Do you do exams and review the history daily? If you are and aren't billing a 99233, you are missing crucial dollars you deserve for your work!

Inpatient Admissions, 99222 and 99223

Do you really think caring for a patient in the hospital costs less than a patient out of the hospital? Apparently Insurance does.

It is the main reason why a decent amount of internal medicine doctors have relinquished their hospital care to doctors who are permanently in the hospital.....

Why should you get paid more for a complete physical with new problems than a patient who is septic and tachycardic?

Does it make any sense?

No.

Which is why I want to make sure you get paid what you should for your hospital care. I am going to cover 2 codes today.

If you have read my previous posts you will understand my philosophy.

1. Doctors often undercode for fear of audits, not because they did less work than they claim.
2. Doctor often think they are documenting properly, but are often wrong.
3. Thus doctors get audited and lose money for their services and the cycle perpetuates....

So with that in mind, let's take a systematic look at the hospital admission The codes 99222 and 99223 are what I will cover, because 99221 should probably not be admitted to the hospital.

Unless of course you have failed outpatient management with them.

99222 requires:
1. A Comprehensive History (See Here)
2. A Comprehensive Examination (See Here)
3. Medical Decision Making of Moderate Complexity

99223 requires:
Same as 99222 except this one key distinction.
Medical Decision Making of High Complexity......

What is the difference between Moderate and High? Not much really.
Try 1 Problem Point and 1 Data Point.

Huh? Ok, I guess if you said huh, you haven't read my other posts......

Medical Decision Making is Judged by 3 things. You need 2 of the 3 at the highest level you code for......

The things?
A. Problem Points. For each of the following things you document you receive points as below

New Problem with work up (4)

New problem no Work up (3)

Est Problem, Worsening (2)

Est Problem Stable(1)


What is the difference between Moderate and Complex? ONE point in this category plus ONE other point in Data, or classified as highest risk!


B. Data Points. For each of the following you document you also get points as below.


Labs Ordered OR Reviewed (1)

Indep Review of EKG/Film/Specimen (2)

Reviewed Old records (2)

Decision to Obtain Old Records(1)

Discuss test with Physician(1)

Order Test EKG/Cath/PFTs (1)


So in this case you need FOUR points to document High Risk, whereas you need 3 points for moderate.

The last item is titled Risk.

Risk is a nebulous little bugger which has been encapsulated in a table by EM University.

Personally I think it may be a little more complex than that, but the table is here for your viewing pleasure.

To meet the Risk criteria for a 99223 (The highest admission code) you need
High Risk

1. One or more chronic illness, with severe exacerbation or progression
2. Acute or chronic illness or injury, which poses a threat to life or bodily function
3. An abrupt change in neurological status
Or if you chose to do
1. Cardiovascular imaging, with contrast
2. Cardiac EP studies
3. Diagnostic endoscopies
4. Discography
5. Elective major surgery
6. Emergency major surgery
7. Parenteral controlled substances
8. Drug therapy requiring intensive monitoring for toxicity (Digoxin/Heparin)
9. Decision not to resuscitate, or to de-escalate care because of poor prognosis

I am certain there are more criteria than this, but I think you get my drift.
Most people you admit have one of 4 things.

1. Infection
2. Exacerbation of Chronic Disease
3. Chest Pain
4. Need Surgery

If you can claim that these conditions are severe, you can claim highest risk......
Or all you have to claim 4 points in Problems and 4 Points in Data.

Most doctors look at EKGs, Most doctors don't say independent review of EKG by me.... There is a huge difference to the insurers. The same is true for radiology studies......If you look at one film and look at one EKG, you have FOUR data points!!!!

That is enough to code at the highest level when you add 4 Problem points, which are probably the easiest to get. Now all you have to do is a comprehensive history and examination, which you better do when admitting a patient!

So In conclusion, most of your admissions will fall as 99223. Just look, take the time to document and get paid what you deserve!

Why coding matters? It IS medicine!

I have been asked by a lot of my peers as to why we need to learn coding. As if the 4-5 billion they (coders and billers) siphon off of your hard work isn't incentive enough, I say that communication and documentation via CPT criteria is just about the highest order language in medicine.

They then laugh at what I am saying. But think about it. How many times have you read someone else's note and had no clue WTF they were talking about or what was in their mind.

It turns out that if you just document your thoughts through the CPT system and according to auditing standards YOU WILL be communicating and no one will ever question your thoughts......

How does this type of documentation work? Well, you start by obtaining a history and making note of things such as

* Location
* Quality
* Severity
* Duration
* Timing
* Context
* Modifying Factors
* Associated Signs and Symptoms

Yes, of course you ask these things. But how many of you put this in your notes? You should? In fact if you do, you not only help other doctors out, but you also get paid more for what you do.....by including 4 of these with the problem, you can bill at E and M codes at the highest levels

Then let's obtain a family history......yes, you can do that. At least get the first 2 generations, Parents and Children or parents and grandparents. Why? Because you pick up diseases. But even if you don't pick them up, you at least document it for someone who may be able to see something in that tree.......

Past medical? Past Surgical? Ask your patients when they were diagnosed with their diseases and the medications that they had tried. Ask about ADRs. Even if you do all these things, unless you document it........

My point is, organize your thoughts on paper and in the way which includes recognition of the CPT auditing system. If you train your brain to think this way, you will be a higher order physician and your reimbursements will go up because of it. But most importantly, your patients will be healthier.