CODING REVIEW FOR ACCESS2MD PROVIDERS
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1 CODING REVIEW FOR ACCESS2MD PROVIDERS May 27, 2015 Tricia Stanley, DNP, RN, ANP-BC, FNP-BC
2 TYPES OF CODES CPT What was done during the visit Two Types CPT Evaluation and Management ICD Why it was done The actual diagnosis code and these must make sense together!
3 ICD-9 Provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease.
4 CPT Code Set accurately describes medical, surgical, and diagnostic services Evaluation/Management Codes ( ) Anesthesia Codes ( ) Surgery Codes ( ) Radiology Codes ( ) Pathology/Laboratory Codes ( ) Medicine Codes ( ) Appendices: Modifiers, Deleted codes
5 V CODES: SUPPLEMENTAL DIAGNOSIS CODES V01 Contact with or exposure to communicable diseases V02 Carrier or suspected carrier of infectious diseases V09 Infection with drug-resistant microorganisms V10 Personal history of malignant neoplasm (i.e. cancer) V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V20 Health supervision of infant or child V21 Constitutional states in development V22 Normal pregnancy
6 V CODES: SUPPLEMENTAL DIAGNOSIS CODES V23 Supervision of high-risk pregnancy V24 Postpartum care and examination V25 Encounter for contraceptive management V28 Encounter for [antenatal] screening of mother V29 Observation and evaluation of newborns for suspected conditions not found V30 Single live born V31 Twin birth mate live born V48 Problems with head neck and trunk V49 Other conditions influencing health status V50 Elective surgery for purposes other than remedying health states V51 Aftercare involving the use of plastic surgery
7 V CODES: SUPPLEMENTAL DIAGNOSIS CODES V56 Encounter for dialysis and dialysis catheter care V57 Care involving use of rehabilitation procedures V58 Encounter for other and unspecified procedures and aftercare V60 Housing, household and economic circumstances V64 Persons encountering health services for specific procedures not carried out V65 Other persons seeking consultation V66 Convalescence and palliative care V67 Follow-up examination V68 Encounters for administrative purposes V69 Problems related to lifestyle V70 General medical examination V71 Observation and evaluation for suspected conditions not found V80 Special screening for neurological eye and ear diseases V81 Special screening for cardiovascular respiratory and genitourinary diseases V85 Body mass index
8 E & M CODING Evaluation and Management
9 WHAT ARE E&M CODES? Describes: Complexity of care provided to a patient for non-procedural visits. The place of service (inpatient or outpatient) The type of service (new vs. established, consult, preventive, ER, critical care, etc) Defined by 3 components The patient history The physical examination Medical decision making
10 DETERMINING THE CORRECT E&M CODE There are three key components to consider when selecting the appropriate E&M: History Exam Medical Decision Making (MDM) All three components must be documented for a new patient (new to clinic or not seen within the past three years). Indicate in CC if patient is new. Only two of the three components must be documented for established patients (seen within the past three years).
11 HISTORY ALGORITHM History Type HPI ROS PFSH Problem Focused (1 point) Expanded Problem Focused (2 points) Detailed (3 points) Comprehensive (4 points) Brief None None Brief Problem pertinent None Extended Extended Pertinent Extended Complete Complete
12 PHYSICAL EXAM Type Either this Or this Problem Focused (1 point) < 1 organ system/body area 1-5 bulleted elements Expanded Problem Focused (2 points) 2-4 Organ Systems/Body areas > 6 Bulleted Elements Detailed Exam (3 points) 5-7 Organ Systems/Body Areas > 2 bulleted elements from 6 areas or > 12 bullets from > 2 areas Comprehensive Exam (4 points) > 8 organ systems/body areas Complete single system examination or > 2 bulleted elements from 9 areas
13 PHYSICAL EXAM Type of Examination Problem Focused Description A limited examination of the affected body area or organ system. Expanded Problem Focused A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s). Detailed An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s). Comprehensive A general multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).
14 MEDICAL DECISION MAKING Based upon Number of diagnoses or management options Amount and complexity of data Overall risk
15 MEDICAL DECISION MAKING (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option. Measured by documentation of the following: Number of diagnoses and/or management options that must be considered. Amount and/or complexity of data to be reviewed. Risk of complications, morbidity and/or mortality, and co-morbidities. Four types Straightforward, Low Complexity, Moderate Complexity, and High Complexity.
16 DOCUMENTING COMPLEXITY Consider the following for risk Chronic illness(es) Well controlled Mild exacerbation Severe exacerbation Acute illness Uncomplicated like allergic rhinitis With systemic symptoms like pneumonitis Consider the following Did you order/review labs Did you order/review X-rays, US, MRI Did you order/review any other testing Did you review or summarize old records Must document this in the note
17 ESTABLISHED PATIENT E&M CODES 2 OF 3 RULE Code History Physical Exam Medical Decision making Time Nursing service only N/A Nursing order Problem Focused (1) Problem Focused (1) Straight forward (1) Expanded Problem Focused (2) Expanded Problem Focused (2) Low Complexity (2) Detailed (3) Detailed (3) Moderate Complexity Comprehensive (4) Comprehensive (4) High Complexity (4) 40
18 Level of Service NEW PATIENT E&M CODES 3 OF 3 RULE History Examination Medical Decision Making Problem focused Problem focused Straight forward complexity Expanded problem focused Expanded problem focused Straight forward complexity Detailed Detailed Low complexity Comprehensive Comprehensive Moderate complexity Comprehensive Comprehensive High complexity
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