Slide 1. Slide 2 The Scream by Edvard Munch, Slide 3

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1 1 Jan DiSantostefano, MS, NP SAS Institute, Inc. Cary, NC November, The Scream by Edvard Munch, in France by a physician, Jacques Bertillion. Bertillon Classification of Causes of Death adopted in the United States. Considered, in effect, ICD-1 because that was the first version of code numbers ICD-6 added mental disorders ICD-9 was the first time procedure codes were added, and the CM designation was included. ICD-11 - the next major update, expected implementation by

2 4 The International Classification of Diseases (ICD) is the classification used to code and classify mortality data from death certificates. The International Classification of Diseases, Clinical Modification (ICD-9-CM) is used to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys. 4 5 Published in the Federal Register in April/May of each year Effective October 1. No grace period. New, revised and discontinued codes or ode.asp. 5 6 October 1, The last regular, annual updates to both ICD-9-CM and ICD-10 code sets will be made. October 1, Limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L October 1, Limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L There will be no updates to ICD-9-CM, as it will no longer be used for reporting. October 1, Regular updates to ICD-10 will begin. 6

3 7 New subcategory Complications of gastric band procedure New code Infection due to gastric band procedure Use additional code to specify type of infection, such as: abscess or cellulitis of abdomen (682.2) septicemia ( ) Use additional code to identify organism ( ) New code Other complications of gastric band procedure Use additional code(s) to further specify complication 7 8 REVISE Mild mental retardation Moderate mental retardation Severe mental retardation Profound mental retardation NEW WORDING Mild intellectual disabilities Moderate intellectual disabilities Severe intellectual disabilities Profound intellectual disabilities Bloodstream infection due to central venous catheter Bloodstream infection due to: Hickman catheter peripherally inserted central catheter (PICC) portacath (port-a-cath) triple lumen catheter umbilical venous catheter Catheter-related bloodstream infection (CRBSI) NOS Central line-associated bloodstream infection (CLABSI) 9

4 Local infection due to central venous catheter Exit or insertion site infection Local infection due to: Hickman catheter peripherally inserted central catheter (PICC) portacath (port-a-cath) triple lumen catheter umbilical venous catheter Port or reservoir infection Tunnel infection Welcome to Medicare Exam IPPE Initial Preventive Physical Examination Intro to Medicare and covered services Annual Wellness Visit AWV Not a PE, a preventive exam Began in January 1, 2005 Once in a lifetime Must be scheduled within 12 months of an individual s enrollment in Part B Waiver of the Medicare Part B deductible May be performed by physician or qualified NPP (non-physician provider) 12

5 13 A review of an individual s medical and social history with attention to modifiable risk factors for disease detection. A review of an individual s potential (risk factors) for depression or other mood disorders. A review of the individual s functional ability and level of safety. Exam required components see next slide Height Weight Blood pressure measurement Visual acuity screen Measurement of BMI (required service effective January 1, 2009), Other factors as deemed appropriate by the examining physician or qualified nonphysician practitioner Performance and interpretation of an EKG Optional, Not Required End-of-life planning, effective for dates of service on or after January 1, 2009 (upon an individual s consent). Education, counseling, and referral, as deemed appropriate, based on the results and review and evaluation of the previous components Complete a brief written plan, such as a checklist, to be given to the beneficiary for obtaining a screening electrocardiogram (EKG), as appropriate, and the appropriate screenings and other preventive services that are covered as separate Medicare Part B benefits 15

6 16 Annual Wellness Visit - AWV Bone mass measurements Cardiovascular screening blood tests Colorectal cancer screening tests Diabetes screening tests Diabetes outpatient selfmanagement training services Medical nutrition therapy for individuals with diabetes or renal disease Pneumococcal, influenza, and hepatitis B vaccines and their administration Prostate cancer screening tests Screening for glaucoma Screening mammography Screening Pap test and screening pelvic examinations Ultrasound screening for abdominal aortic aneurysms Service offered as of Jan 1, Different from IPPE Cannot be offered until patient has been on Medicare for at least 12 months. No co-insurance or deductible Preventive visit, not necessarily an exam A physician who is a doctor of medicine or osteopathy A PA, NP, CNS A medical professional (health educator, registered dietician or nutrition professional or other licensed practitioner) or team of such medical professionals, working under the direct supervision of a physician 18

7 19 Establishment of an individual s medical / family history. Establishment of a list of providers and suppliers that are regularly involved in providing medical care to the individual. Measurement of an individual s height, weight, BMI (or waist circumference), BP, and other routine measurements, based on the patient s medical and family history. continued Detection of any cognitive impairment. Review of potential risk factors for depression, including past or present experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current dx of depression. Review of the individual s functional ability and level of safety based on direct observation or a screening tool. continued Establishment of a written screening schedule for the individual, such as a checklist for the next 5 10 years, as appropriate, based on recommendations of USPSTF, ACIP, individual health status, screening history, and ageappropriate services covered by MCR. Personalized Prevention Plan Services - PPPS continued 21

8 22 Establishment of a list of risk factors and conditions for which primary, secondary, tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any risk factors or conditions identified through an IPPE, and a list of treatment options and their associated risks and benefits. continued Furnishing of personalized health advice to the individual, including: Referral to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process. Voluntary advance care planning removed from requirements 24

9 25 An update of the individual s medical/family history. An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV. Measurement of an individual s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual s medical/family history Detection of any cognitive impairment that the individual may have as defined in this section. An update to the written screening schedule for the individual, as that schedule is defined in this section, that was developed at the first AWV providing PPPS. An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs. Any other element(s) determined by the Secretary of Health and Human Services through the National Coverage Determination process.

10 28 2 digit code, explaining special circumstances May be alpha-numeric Appended to CPT code, E/M or Procedure code Need to show medical necessity justifying both codes Deleted (2010) Prolonged E&M services 99354(-99359) Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour List separately in addition to code for office or other outpatient evaluation and management service with Unrelated E&M service provided during the post-operative period by a single provider Patient comes in for thrombosed hemorroid one week after hernia surgery 30

11 31-25 Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service New wording added in 2008 for clarification to clarify the modifier s use and stress the importance of documentation to support that the E&M service is significant and separate from the same-day service or procedure year old well-child exam c/o chest pain when running at school Separate history, exam docuemnted Can bill modifier 25 with Is it covered? c/o ear pain and otitis media found on exam. Is separate history & exam needed? A 44-year-old established patient presents for her annual well-woman exam. A complete review of systems is obtained, and an interval past, family and social history is reviewed and updated. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise. Appropriate labs are ordered 33

12 34 The patient also requests advice on hormone replacement therapy. She is anticipating menopause but is currently asymptomatic. Preventive medicine services include counseling or guidance on issues common to the patient's age group The patient also complains of night sweats, hot flashes and lighter, irregular menses. After a discussion of treatment options, risks and benefits, a prescription for estrogen replacement is given The patient also complains of fatigue, hair loss, feeling cold and lighter menses. On exam, mild hair thinning and areflexia are noted. The nurse practitioner orders a complete blood count and thyroid stimulating hormone test with the intention of writing a prescription after reviewing the test results. 36

13 37 The patient also complains of bilateral knee pain in the morning. Tenderness and swelling are found on exam. The patient is given a nonsteroidal anti-inflammatory drug prescription The patient also states that home monitoring has shown fasting blood sugars of 120 mg/dl to 180 mg/dl and some random sugars over 300 mg/dl. The status of previously diagnosed stable conditions would be considered part of the preventive medicine service and not separately billable The patient also complains of vaginal dryness, and her prescriptions for oral contraception and chronic allergy medication are renewed. 39

14 40 Discontinued procedure. Attempted sigmoidoscopy, but unable to enter colon with smallest scope. Submit bill with full fee, and modifier. Attach documentation, along with letter explaining why procedure was discontinued. Apply also to removal of IUD, implantable SQ birth control Post-operative management only Surgeon in another locality provides surgery, you provide follow-up care Procedures and services not usually reported together. Different area of injury Different procedures Surgery on different sites or organ systems Separate incision/excision Separate lesions Treatment to separate injuries 42

15 43 Physical Therapy A physical therapist treat a patient with different problem. One for his neck and one for his back. During the same session, (CPT 97110) 15 minutes each site (for back and neck). Code first line without Mod- 59 Code second line with Mod- 59 >>>> make sure you point the right diagnosis on each line A Dermatologist performs simple repair of a superficial wound to the right arm and also performs a debridement of another site but on the same arm. Modifier -59 is very useful for coding and billing dermatology services. 45 Pain Management The pain doc performs a facet nerve block L1- L2 and an SI Injection on the same session: x 1 unit mod -59 x 1 unit

16 46-76 Repeat procedure by same health care provider EKG, or other test to monitor responses to medications or change in symptoms Second nebulizer treatment in one day Repeat procedure by another health care provider. EKG done by one provider. Reviewed by another provider and repeated due to questions regarding reliability. 48 Indicates an unrelated procedure by the sam provider during a post-op period. Use this modifier on the CPT code of the new procedure. A different and unrelated diagnosis is also needed.

17 49-91 Repeat clinical diagnostic laboratory test Used to report lab test repeated on same day in order to provide subsequent results Example Blood sugar tests after administration of insulin 50 Modifier 91 is not used when there is a problem running a test and it is repeated. Modifier 91 is not used when the test results seem abnormal and the test is re-run for confirmation purposes. Modifier 91 is not used when the description the test provides for a series of results, for example a glucose tolerance test.

18 51 18 YEARS AND UNDER 19 YEARS AND OVER Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration ; each additional vaccine/toxoid component (List separately in addition to code for primary procedure.) Immunization administration one vaccine Immunization administration - second or additional vaccine same as nasal or oral same as nasal or oral 52 DELETED CODES Reported per Immunization Younger than 8 years Counseling required by physician Codes differ based on route of administration (eg, injectable versus intranasal). NEW CODES Reported per Component 18 years and younger Counseling required by physician or other qualified health care professional Use for all routes of administration Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure.)

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