Top 10 Errors to Avoid in 2011: Pediatrics Updates

Transcription

1 Top 10 Errors to Avoid in 2011: Pediatrics Updates Jacqueline J Stack, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC 1 Agenda Newborn Care Critical Care Intensive Care Transport Preventive Immunizations Inpatient Observation Outpatient Modifiers 2 1

2 Newborn Care Normal Newborn visit, initial service Normal Newborn visit, day 2 Discharge normal newborn day 3 Normal Newborn evaluated & discharged same day Normal Newborn Care Initial hospital or birthing center care normal newborn Initial care other than hospital normal newborn Subsequent hospital care per day normal newborn Initial care hospital or birthing center normal newborn admit & discharge same day 4 2

3 Example The baby s mom undergoes a repeat cesarean section of a healthy full term 7lb. infant. Your physician examines the baby the next morning He reviews the records Examines the infant, and speaks to the parents Provider sees them three days in the hospital Provider performs circumcision on day initial service for day 1, ICD V Subsequent hospital care, ICD V30.01 & circumcision, ICD V50.2 for day for day of discharge, ICD V Attendance at Delivery OB/GYN calls your provider to the delivery room for a possible difficult delivery. Your provider documents; The request for attendance The provider s immediate interventions Discussion with parents Code Attendance at delivery 6 3

4 Attendance at Delivery Physician attends delivery at request of delivering physician Initial drying Stimulation Suctioning Blow-by oxygen CPAP Assigning Apgars Discussion of care with parents May be reported with; normal newborn sick newborn initial intensive care critical care Intubation laryngoscopy catheterization 7 Standby Services/Resuscitation Physician standby requested (cannot attend to any other patients and must be immediately available) (choose appropriate 30 min units) If less than 30 minutes cannot be billed Newborn resuscitation

5 Initial Neonate Intensive Care Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires observation, frequent interventions and other intensive care services Day of admission or day of re-admission Less than or equal to 28 days Weight not a factor Neonate who requires intensive care but does not qualify for critical care. Requires frequent observation 9 CPT For the initiation of inpatient care of the normal newborn report For initiation of the care of the critically ill neonate use For initiation of inpatient hospital care for the neonate not requiring intensive observation, frequent interventions or other intensive care services use

6 Example On day 1 of the hospital stay the newborn starts to show signs of persistent hypothermia. Your provider documents; Intensive observation Frequent interventions Continual monitoring Code normal newborn service, ICD V30.01 and with modifier 25, ICD Subsequent Intensive Care Subsequent intensive care, per day, recovering very low birth weight infant Present body weight less than 1500 grams Subsequent intensive care, per day, recovering low birth weight infant Present body weight of grams Subsequent intensive care, per day, recovering infant Present body weight of grams 12 6

7 CPT VLBW/LBW or not critically ill, but continue to require any of the following: Cerebral Palsy monitoring, and/or Vital sign monitoring, and/or Heat maintenance, and/or Enteral /parenteral nutritional adjustments, and/or Observation by the healthcare team under the direct supervision of a physician Once a day by one physician (per diem code) 13 Example The baby has been home for a few weeks and mother notices he s having trouble breathing. Baby returns to the Emergency Department at three weeks old with respiratory distress. The ED physician provides an hour of critical care and the baby is admitted to the PICU on the same day by the pediatrician. ED physician = Critical Care first min. Pediatrician = Initial Inpatient neonatal critical care, per day for neonate 28 days or less 14 7

8 Outpatient to Inpatient Cross Over Critical care in the ED of patient five years or younger ( ) that results in an inpatient admission by the same provider are reported with neonatal or pediatric critical care codes ( ) because these codes are per day and cannot be billed more than once per day 15 Definition of Critical Care Direct delivery by a physician Acute impairment one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition High complexity decision making to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition Typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure 16 8

9 Services Included in Critical Care Bundled or Global Services: Interpretation of cardiac output measurements Chest X-rays Pulse oximetry Blood gases Information data stored in computers (ECG s, blood pressure, hematologic data) Gastric Intubation Temporary transcutaneous pacing Ventilatory management Vascular access procedures All services normally bundled into Critical Care codes Critical Care Ambulatory Setting (e.g. ED or office) for patient of any age Inpatient Setting for patient 72 months of age or greater Inpatient Setting, Critical care to neonate by 2nd physician of different specialty, any age Transport Setting, Physician in transport of child greater than to 24 months 18 9

10 Inpatient Neonatal Critical Care Initial, Subsequent, Per diem May be reported with: Delivery room attendance (when requested by attending) Delivery room resuscitation Less than or equal to 28 days of age The initial day neonatal critical care code (99468) can be used in addition to (physician is present for the delivery) or (resuscitation) as appropriate Other procedures performed as a necessary part of the resuscitation (eg, endotracheal intubation [31500]) 19 Example The baby is out of the PICU on day 3 and appears to be slowly recuperating. The physician performs an expanded problem focused history and physical exam on Lucky who is experiencing mild transient tachypnea. He requires low-flow nasal cannula and small gavage feedings. The baby is discharged the next day. Code subsequent inpatient visit for day /99239 for discharge day 4, dependent on time 20 10

11 Pediatric Critical Care Transport Services Critical Care services delivered by a physician, face-to-face, during an interfacility transport 24 months of age or younger first minutes of hands-on care, 24 months of age or younger each additional 30 minutes Critical Care services delivered by a physician, face-to-face, during an interfacility transport older than 24 months of age first minutes each additional 30 minutes 21 Inpatient Pediatric Critical Care Initial Subsequent Per diem 29 days to 24 months old They represent care starting with the date of admission (99471, 99475) and subsequent day(s) (99472, 99476) the infant or child remains critical. These codes may be reported only by a single physician and only once per day, per patient in a given setting

12 Inpatient Pediatric Critical Care Initial Subsequent Per diem 2 years to 71 months old If patient in PICU and crosses from 23 to 24 months, would begin PICU with but report subsequent with Keep track of ages, or will receive denials 23 Office Visit Mom brings patient in because she s concerned he isn t breathing well again. The patient is a 4 yr. old asthmatic. Physician documents two nebulizer treatments, physical exam after each shows decreased wheezing. The nurse documents her evaluation of use and education of home use of MDI and provision of medication. Codes? 24 12

13 Inhalation Treatments Detailed office visit Initial Pressurized or nonpressurized inhalation treatment Second inhalation treatment Demonstration and/or eval. of patient use of MDI Diagnosis code for extrinsic asthma with acute exacerbation 25 Prolonged Services Patient with difficulty breathing in office receives E/M and nebulizer treatment. Physician evaluates before and after two additional treatments. Direct face-to-face contact with patient and physician beyond the usual service duration. The start and end times of the visit shall be documented in the medical record along with the date of service. Start 2:00 End 3:10pm E/M in office documentation supports (25 minutes) Nebulizer nd treatment x1 (45 additional minutes total face-to-face time beyond the initial 25 minute visit)

14 Return to the Hospital Mom takes the patient home with the MDI, however, the patient is found to be hypoxic and is admitted. The pediatrician sees the patient in the hospital and documents a comprehensive history & comprehensive physical and moderate level medical decision making. Code Initial hospital care, per day, ICD (hypoxemia) 27 Transfer The 4-year-old patient is not responding to treatment; he is moderately ill with respiratory distress. X-Ray shows right lower lung infiltrate with flattened diaphragm. The patient is transferred to PICU and the physician begins critical care services. Codes critical care, ICD 486 (pneumonia) 28 14

15 Initial Observation Care Initial observation care which require these 3 key components: A detailed or comprehensive history A detailed or comprehensive examination Straightforward or low complexity medical decision making Initial observation care which require these 3 key components: A comprehensive history A comprehensive examination Moderate complexity medical decision making Initial observation care which require these 3 key components: A comprehensive history A comprehensive examination High complexity medical decision making 29 Subsequent Observation Care Problem Office and Other Outpatient E/M in a hospital setting Administration of Insurance Benefits (office visit copays) Solution Create codes that match subsequent hospital care Rationale Existing Observation Codes had structure and value close to hospital inpatient services 30 15

16 Subsequent Observation Care Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care Usually, the patient is stable, recovering, or improving Physicians typically spend 15 minutes at the bedside and on the patient s hospital floor or unit. 31 Subsequent Observation Care Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of high complexity. Counseling and/or coordination of care Usually, the patient is stable, recovering, or improving Physicians typically spend 25 minutes at the bedside and on the patient s hospital floor or unit

17 Subsequent Observation Care Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Detailed interval history; Detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care Usually, the patient is stable, recovering, or improving Physicians typically spend 35 minutes at the bedside and on the patient s hospital floor or unit. 33 Things to Remember about Subsequent Observation Care Do not report in conjunction (on the same date) with initial observation care Observation care discharge services and subsequent observation may not be reported on the same day Do not report observation services on the same day as office or emergency services

18 Discharge Observation Care Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from observation status if the discharge is on other than the initial date of observation status. 35 Initial and Discharge Observation Care on the Same Day Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem (s) and the patient s and/or family s needs. Usually the presenting problem (s) requiring admission are of low severity

19 Initial and Discharge Observation Care on the Same Day Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem (s) and the patient s and/or family s needs. Usually the presenting problem (s) requiring admission are of low severity. 37 Initial and Discharge Observation Care on the Same Day Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem (s) and the patient s and/or family s needs. Usually the presenting problem (s) requiring admission are of low severity

20 Example 7:00 am Thursday morning A 12-year-old female with nausea, vomiting, and crampy abdominal pain presents to the emergency department, is evaluated and admitted to observation status. The attending physician does not feel she can be discharge that date and reports 99219, initial observation care. A surgical consult is requested and the surgeon reports 99244, office consultation. 39 Example (cont.) 7:00 am Friday morning The patient is responding to therapy. Although the patient s condition has improved, there are concerns regarding the abdominal condition, requiring continued observation. She is seen by both her attending physician and the surgeon. Both report 99225, subsequent observation care. 8:00 am Saturday morning The patient has responded adequately for discharge. The attending reports 99217, observation care discharge services

21 Preventive Medicine Revision of text to clarify existing policy: Vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg. vision, hearing, developmental) identified with a specific CPT code are reported separately. 41 Well Child Check The baby comes to the pediatrician for a scheduled 2 month preventive service. The physician documents a multisystem examination, comprehensive history and counsels the family on age appropriate vaccines. CPT 99391, ICD V20.2 and codes for vaccines and other screenings 42 21

22 Screening Services Per CPT instructions; screening tests identified with CPT codes are coded separately Hearing screening and assessment Screening test pure tone, air only Full pure tone audiometric assessment Acoustic reflex testing Urinalysis Screening Services Vision Screening and assessment Screening test of visual acuity, quantitative, bilateral (Snellen chart) Screening lab work Collection of capillary blood PKU test Venipuncture Access vein for blood draw Preparation of specimen

23 Immunization Administration for Vaccines/Toxoids Codes 90465, 90466, 90467, deleted and replaced with new immunization administration codes and for patients 18 years of age and under who receive counseling. 45 CPT and 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 each additional vaccine/toxoid component (list separately in addition to code for primary procedure) 46 23

24 90460 and (counseling) vs (without counseling over 18) Use for each vaccine administered For vaccines with multiple components (combination vaccines), report in conjunction with for each additional component in a given vaccine The work of counseling issue does not apply to : they remain per vaccine and by route of administration. 47 Coding for a 2-month-old Infant Based on the Current Immunization Schedule Immunization DTaP (IM) Rotavirus (oral) Hepatitis B and Haemophilus influenza type b (IM) Vaccine and administration Codes Admin: 90460, 90461, Vaccine: Admin: Vaccine: Admin: 90460, Vaccine: Inactivated Poliovirus (IM) Pneumococcal conjugate vaccine, 13 valent (IM) Admin: Vaccine: Admin: Vaccine: TOTAL: 90460X5 and 90461X

25 Vaccine Administration Billing Vaccine administration codes Patient any age and no MD face-to-face counseling Reimbursement troubles? PositionPaper.doc VFC coding state specific Vaccines for Children federal program Bill just vaccine/follow state guidelines 49 Vaccine Counseling Pediatric specific codes and Patient younger than 18 years Physician personally must perform face-to-face vaccine counseling Common discussion/education topics; Refusal of all vaccines. Desire to not give as many vaccines at one time. Is there mercury (thimerosal) in any vaccines? When I was a kid everyone got chicken pox and was ok. What about autism? 50 25

26 Link to Complete 2011 AAP Vaccine Coding Table Vaccine Coding Table Includes CPT and ICD-9-CM codes for 43 Vaccines and 2 Globulin List by Manufacturer & Brand ha617f6d55ry1de9623ebqrig3 51 Vaccines CPT Early Release Vaccine Product Codes Early Release on the Website Published in CP each October- Active January 1st Appear Twice a Year on the AMA website Early Release January 1st and July 1st Codes Become Active for use 6 months after appearing

27 2009 H1N1 Flu Pandemic H1N1 Pandemic Vaccine and Administration Codes and posted to the AMA website in July of Influenza virus vaccine, pandemic formulation, H1N H1N1 immunization administration (intramuscular, intranasal), including counseling when performed 53 New Recommendations for the 2010/2011 Flu Season H1N10 products (90633) developed for the 2009 H1N1 pandemic have expired and should not be administered. Reformulated seasonal flu vaccines which incorporate the H1N1 virus and related viruses should be reported with the seasonal influenza vaccine codes (90655 et al) and vaccine administration codes (90460, 90461, 90471, and 90474) AND NOT and

28 Series of Codes Added for Potential Future Pandemic Influenza virus vaccine, pandemic formulation, live, for intranasal use Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use 55 FDA Approval Received Human Papilloma virus, (HPV) vaccine, types 16, 18, bivalent, 3 does schedule, for intramuscular use (October 16, 2009 approval received) Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (December 23, 2009 approval received) Pneumococcal conjugate vaccine, 13 valent, for intramuscular use (February 23, 2010 approval received) 56 28

29 1 New Vaccine Product Code Added Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine, tetanus toxoid conjugate (Hib- MenCY-TT), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use 57 Surgery The baby returns to the hospital for placement of a central venous access and repair of right and left inguinal hernia. The first venous access fails so the surgeon has to place a second one later Bilateral hernia repair first catheter redo of catheter on same day 58 29

30 Surgery/Procedure Modifiers 22 Increased Procedural Service Greater than typical work during a procedure Requires clear documentation - payer specific 50 Bilateral Procedure Right and left arm fracture repair Multiple Procedures payer specific Repair of simple wound of arm and wart removal toe 12001, Surgery/Procedure Modifiers Continued 52 Reduced/-53 Discontinued Services Not able to complete circumcision (danger to patient ) 58 Staged or related procedure during global Planned at the time of the initial surgery Closure of perineal urethrostomy 5 weeks post hypospadias repair, Distinct Procedural Service Nebulizer and inhaler teaching same day 94640,

31 Surgery/Procedure Modifiers Continued 63 Procedure performed on infants weighing less than 4 kg. Append modifier to any procedure on an infant less than 4 kg that does not specify infant in CPT description 76 Repeat procedure or service by the same physician Nebulizer treatment repeated 94640, Unplanned return to the OR by same MD for related procedure Treat abdominal hemorrhage post surgery, Returns During Global Shortly after recuperating from his recent surgery Lucky was seen again in the office for an upper respiratory infection. Pediatrician documents an expanded problem focused visit. Visit during global normally would not be charged, however this is an unrelated issue from surgery Codes with modifier 24, ICD

32 E/M Modifiers 24 Unrelated E/M by the same MD during postop period Seeing patient for ear infection 7 days after wound repair in office 25 Significant, Separately Identifiable E/M by the same MD on the same day of the procedure or other service Finding unknown significant illness or injury during routine preventive visit 63 E/M Modifiers Continued 52 Reduced Services You are unable to complete a visit as planned due to disruptive child behavior or family member behavior 57 Decision for Surgery Surgeon consults on a patient for abdominal pain. During visit determines urgent strangulated hernia repair necessary. Surgeon report (consults may be payer specific) and for surgery 64 32

33 Resources AAFP AMA - CPT Changes An Insider s View 2011 AAPC American Academy of Pediatrics AAP Coding for Pediatrics book 2009 (14th edition) CMS Medical Group Management Association - AMA - CPT Changes An Insider s View