Family Practice. P r e s e n t e d B y : D i n a R a e h s l e r, R H I T J u n e 2 8,

Transcription

1 Family Practice CODING P r e s e n t e d B y : D i n a R a e h s l e r, R H I T J u n e 2 8,

2 New Patient/ Consultation New Patient Patient has not received any professional services from the physician, or another physician in the group, of the same specialty, within 3 years. Family Practice, Internal Medicine, and Pediatrics are considered different specialties. Consultations Can be a new or established patient Service provided by a physician whose opinion or advice regarding an evaluation of a specific problem is requested by another appropriate source Documentation requirements Reason for request Requesting provider name Report communicating back

3 Pre-operative Clearance Routine Pre-op ( ) There is no request for advice or opinion on a specific condition(s), routine clearance Diagnoses Primary V72.83-Specified pre-op exam Secondary is reason for surgery If reason for surgery is not specified choose V72.84-Unspecified preop exam Pre-op Consultation ( ) Clearance for surgery for a specific condition(s) that might cause complications with the surgery Diagnoses Primary diagnosis is V Specified pre-op exam Secondary is the reason for surgery Last you would list the condition being evaluated

4 Billing Based on Time Counseling and/or Coordination of Care Over 50% of visit is counseling/coordination of care Must be staff time, no resident time Outpatient face-to-face time only Inpatient face-to-face and time spent on floor on patient Often used when doing follow-up on a patient with several conditions and education is needed Counseling on test results Document using.bbot

5 Preventive Care Use Patient has scheduled an annual exam or routine physical. Establish care with no concerns to discuss. Documentation Must clearly state in the note that the patient is there for a routine physical or annual exam. Exam should be age and gender appropriate.

6 Preventive Care Separately Billable Procedures Pap (Q0011) Wet prep (Q0091) Breast/Pelvic Exam (G0101) Documentation requirements (next slide) Digital Rectal Exam (G0102) IUD Insertion (58300) Removal (58301)

7 Breast/Pelvic Exam A Screening Pelvic Exam (including a clinical breast examination) (G0101) must include at least seven of the following eleven elements Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge; Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses; External genitalia (for example, general appearance, hair distribution, or lesions); Urethral meatus (for example, size, location, lesions, or prolapse); Urethra (for example, masses, tenderness, or scarring); Bladder (for example, fullness, masses, or tenderness); Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele); Cervix (for example, general appearance, lesions or discharge); Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support); Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); Anus and perineum.

8 Preventive Care Additional Services Preventive Counseling 15 min or greater ( ) Diet, Exercise, Substance Abuse, Sexual Practices, Injury Prevention Documentation must support time spent Problem-Oriented Service ( ) If patient has another problem he/she would like to address during the visit or that is discovered and requires separate medical decision-making it is possible to bill an E/M in addition to the preventive code. If additional E/M is warranted, documentation must support and make clear that this is in addition to the chief reason for visit (routine physical).

9 Preventive Care Insurance Coverage/Payment Many commercial insurances will cover one preventive visit per year. Medicare does not cover preventive care visits; however, we do a carve-out of charges. This means that the cost of any other payable services (additional E/M, pap, breast and pelvic, etc.) are deducted from the cost. What remains is billed to the patient. Patients may always contact the business office for a payment plan. Document and bill based on services, not coverage.

10 Child and Teen Billable Services Preventive visit ( ) Complete Child & Teen (S0302) DHS and PMAP coverage All (varies by age) recommended elements performed/documented (EPSDT), ENG Developmental Screening (96110) PEDS, MPSI-R Document tool used, pass/fail Mental Health Screening (96110-UC) ASQ-SE, PSC Document tool used, pass/fail Anticipatory Guidance ( ) Problem visit ( )

11 Prenatal Care Initial OB Visit Confirmation of Pregnancy and OB record not started (separately billable) Diagnoses should be confirmation of pregnancy (V72.42) Lack of menses (626.0) OB record started (included in global package) Prenatal Care (59425-AP) Initial history and physical examination Routine visits

12 Prenatal Care High Risk Services Coverage is different among payers At Risk Assessment (H1000) Completed twice for all patients; once at initial OB visit and once at weeks. Provider (physician, certified nurse-midwife, certified nurse practitioner) billing this service must sign assessment form At risk enhanced service; antepartum management (H1001) Billed once per pregnancy At Risk Education (H1003) Up to one hour H1003 Each additional hour H Billed once per pregnancy Separate Problem Visit ( ) Complications (e.g., preterm labor, pregnancy induced hypertension, bleeding) Problems unrelated to pregnancy (e.g., pneumonia, diabetes, chronic hypertension, URI)

13 Minor Procedures Commonly Missed Billable Procedures Skin biopsy Single lesion Each additional lesion (add on code) Lesion destruction (describe lesion and method of destruction) Benign/Wart (up to 14) Premalignant (first lesion) lesions (add on code) Skin tag removal Each additional 10, or part thereof (add on code) Injections of therapeutic or diagnostic agent Small joint or bursa (eg, fingers, toes) Intermediate joint or bursa (eg, Temporomandibular, wrist, elbow, ankle) Major joint or bursa (eg, Shoulder, hip, knee, subacromial bursa) 20610

14 Minor Procedures Commonly Missed Billable Procedures (cont.) Avulsion of nail plate, partial or complete, simple Single Each additional (add on code) Excision of nail and nail matrix, partial or complete, for permanent removal Ingrown or deformed nail Cerumen removal one or both ears Document instrument used (eg, suction, cerumen spoon, delicate forceps) Removal of foreign body No anesthesia Incision and drainage of abscess Simple or single Complicated or multiple

15 Need Coder Review Unsure of what performable to choose, type need under LOS field for need coder review

16 Contact Information Christine Pfeifer -HFA Coding Director Dina Raehsler -HFA Coding Educator Marie Medes -Inpatient Coding Supervisor Leticia Estrada -(HCS,HCN, HCE) Outpatient Coding Supervisor Autumn Grabowski -(FMC) Outpatient Coding Supervisor

17 Disclaimer The content of this booklet is current as of June 2010, but is subject to change. Please notify if you become aware of any contradictory or obsolete information contained in this booklet. The information contained in this booklet is intended only for coding & documentation education and only for the individual use of the person or organization to which it was given by HFA Coding Education. Any other use of this information (including without limitation, reprint, transmission or dissemination of all or part of this information), without written permission of HFA Coding Education, is strictly prohibited.