2015 CPT CODING What s new?

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1 DISCLAIMER What s new? Richard Lander, MD, FAAP National Discount Vaccine Alliance-a GPO Resources in Physician Management Services- a consulting company Sanofi and Merck-speaker I wish I had more! Section on Administration and Practice Management (SOAPM) Home to pediatricians interested or involved with the management or administration of pediatric practices. Provides both basic and cutting edge administration and practice management information to its members. Benefits: SOAPM LISTSERV discussions SOAPM s newsletter soapmnews (bi-annual) Pediatric Practice Managers Association SOAPM NCE programs Open to all FAAPs, Resident Fellows, and eligible Affiliate Members with an interest or active in practice management. Applications for Fellows and Affiliate Members are available on the AAP Member Center at: 3 day old Jeffrey is in your office for the first time for a well visit. Do you code a b c d. none of the above d. None of the above Jeffrey was seen by you in the newborn nursery and therefore is not a new patient 1

2 You haven t seen 4 y/o Erica in over 3 years but she is in today with complaints of abdominal pain and severe headaches. Because it has been 3 years you decide to do a comprehensive visit. a b c d. none of the above a I know I said 3 years but your partners have been seeing her. Her parents don t like you but since everyone else is off they are stuck with you. If no one in the practice had seen her in over 3 years then you could have used a new patient code, which pays you more money There is nothing that is basic in CPT coding. Have all the facts available, choose your code carefully, and pray that the Insurance company will accept your codes. Even if you code correctly they can arbitrarily choose not to recognize the codes If your claim is rejected first look for the reason of the denial: incorrect info-id#, dob>correct and resend insurance terminated-contact the patient claim downcoded-review your documentation and if you are right, appeal What do you do if your appeal was denied but you know that you followed proper CPT rules and your documentation supports your level of coding? a. re-appeal b. call the medical director c. contact the AAP d. all the above The answer is d, all the above. even if your second appeal is denied you can file an executive appeal unless it is against the MCO s policy a medical director can overturn the denial contact your local AAP chapter, fill in a hassle factor form and/or contact Lou Terranova at

3 A MAJOR CHANGE THAT ISN T 59 modifier-distinct procedural service separate and distinct from another non e&m xe-separate encounter happened during a separate encounter xs-separate structure performed on separate structure/organ Modifier 59 of the main service xp-separate provider performed by different provider xu-unusual non-overlapping service does not overlap usual components of the main service Application of Fluoride Varnish in use for many years developmental screening tools Denver, ASQ emotional screening tools Edinburg Post Partum Depression PHQ 9, psc, psc-17, psc-y application of topical fluoride varnish by a physician or other qualified health care professional 2015 CPT CODES CASE MANAGEMENT Reporting face to face and non ftf services provided by clinical staff who are directly supervised by a physician or other qualified health care professional Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. (Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately) 2015 CPT CODES Chronic Care Management Services 3

4 99487 Complex chronic care management services, with the following required elements: same as plus establishment or substantial revision of a comprehensive care plan moderate or high complexity medical decision making 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (Report with 99487) Complex Chronic Care Management Services reporting healthcare professional responsible for management/coordination of care only one hcp can utilize the code q30d begins day of discharge-29 days must include one face-to-face visit includes discharge, on going evaluation and interaction with family or other hcp first face-to-face not reported separately and can be reported(discharge services not counted as 1 st face-to-face Cannot be reported during global surgical time cannot bill medical teen conferences prolonged services w/o patient , (etc)-education and training telephone or online communication within 2 business days f-t-f within 14 calendar days of discharge moderate medical decision making communication within 2 business days f-t-f within 7 calendar days of discharge high complexity mdm 4

5 Why spend all this money and time to implement when they are already planning ICD 11? (release 2019?) is not new, is used by many countries and we, the USA have lagged behind for too long NEW IN 2015 You will have to utilize the codes after October 1, 2015 to be paid by the insurance companies as they will not honor the ICD 9 codes. Your HCFA 1500 claims will not be processed! However both the payers and the providers will need to support ICD 9 codes for claims submitted prior to October 1, 2015 Shouldn t it be easy to simply crosswalk ICD 9 codes to? Can you put a round circle into a square hole? The number of codes are so extensive because they will now demonstrate: laterality (right vs left) specificity (thumb, pointer finger, etc) reasons or causes where did it happen (home, work) how (jumping-trampoline) The new codes have 3-7 characters the first is an alpha all the letters except for U the second is numeric the third to seventh is either X is sometimes used as a fifth character placeholder to allow for future expansion 5

6 What is one of the more common problems we see in our pediatric offices? Characters 1-3=category Characters 4-6=etiology, site etc Character 7=extension Acute supporitive otitis media w/o rupture ICD H asom w/o rupture R ear H asom w/o rupture L ear H asom w/o rupture bilat H asom w/o rupture recurrent R Etc. Etc. Etc. Want more?? ICD unspecified otitis media H66.90 om, unspecified, unspecified ear H66.91 om, unspecified R ear H66.92 om, unspecified L ear H66.93 om, unspecified, bilat Before we leave lets make sure we really understand CPT basics 2015 CPT CODES CC - earache HPI - 3 day hx of left ear pain, ib helps PE - red left TM, edematous nasal turbinates, bilat shotty cervical nodes, right pinna erythematous Amoxicillin 200mg bid x 7 days prescribed a c b d. None of the above CASE EXAMPLE 6

7 a is the correct answer The answer should have been b since we had 3 points of the HPI, examined 3 organ systems and had low complexity medical decision making. However since there was no ROS cannot be used CASE EXAMPLE It is 6:00 pm and you have just seen your last patient. Your office hours are posted that you close at 5:30. The phone rings and you remember that your staff forgot to forward the phones. You tell the mom to bring the child right over to the office, you will wait for them. The visit turns out to be for abdominal pain. How do you code it? The answer is c , a b c , d , Your work during the visit warrants the but you really saw the patient after hours is for services provided in the office outside of regularly scheduled hours Let s change the scenario. It is 6:00 pm and you have scheduled office hours until 7:00. Same call and you tell the patient to come right over. a and b and c and b and is correct is used for services rendered in office during regularly scheduled evening, weekend or holiday hours If you selected c and you thought that since you told the patient to come right over you are entitled to use this office service on an emergency basis 7

8 If when the patient came in it disrupted your patient schedule (you saw them ahead of someone else) you are entitled to use the In this case you would code the visit 99214, and Will you get paid for all codes? Nothing to lose by trying. You need to convince the MCO that by seeing the patient in your office instead of the Emergency Department at that hour, you have saved them money! You have spent 40 minutes on discharging a patient in the hospital. a b c CASE PRESENTATION c is for discharge day management greater than 30 minutes b is for discharge day management less than 30 minutes CPT CODING IS NOT HARD BE CAREFULL, USE THE CORRECT CPT CODES, DOCUMENT WHAT YOU HAVE DONE AND REAP THE BENEFITS CASE PRESENTATION 8