Welcome! Today s program is sponsored by Health Care Education and Training, Inc., Region X Training Project
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Raymond Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is president and Co-Founder of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than 850,000 annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing and reimbursement in addition to authoring two books and dozens of articles. CPC-from the American Academy of Professional Coders CHBME- from the Healthcare Billing & Management Association
Priority Management Group, Inc. Presents Priority Management Group, Inc. 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 www.gopmg.com
Agenda Introduction Contraceptive ICD Overview E&M Visit Appropriateness Contraceptive Coding Options Summary
ICD-9 Examples ICD codes are translation of A&P of SOAP note V Codes Typically avoid as primary ICD code with E&M codes EXCEPTION: Preventive Visit & Contraception Management Issues when billed with E&M problem visit codes Possibly avoid use with 99201-99205 and 99211-99215 Try Anticipatory Guidance & Risk Factor Reduction Codes 99401-99404 Elevated Blood Pressure without mention of HTN: 796.2 Pregnancy Test Results (V72) ACOG recommends: V72.40 - If the encounter is to test for a suspected pregnancy and the patient leaves w/o knowing the results V72.41- If the test is negative V72.42- If the test is positive & OB record is not initiated
ICD to CPT Linkage Example ICD Codes in order of Provider s Perceived Acuity 1. Pelvic Pain: 625.9 2. Exposure to Venereal Diseases: V01.6 3. Negative Urine PT: V72.41 4. Condyloma: 078.10 5. ASCUS PAP: 795.01 6. Oral Contraceptive Management: V25.01 Rendered Services Linked ICD (Above) A. 99214-25 (Level 4 Established Patient Visit) 1, 2, 3, 4, 5, & 6 B. 56515 (Destruction of Vulva Lesions, Extensive) 4 C. 81025 (Urine Pregnancy Test) 3 D. Q0091Pap Conveyance 5 E. 36415 Venipuncture RPR (Outside lab to bill) 2
ICD-9 Examples (Continued) Annual Exam V70.0- Annual adult preventive V72.31- Annual GYN preventive with or without Pap Encounter for Contraceptive Management (V25); S Codes for FamPACT are best Prescription of OCP: V25.01 Initiation of other contraceptive measures: V25.02 Encounter for ECP: V25.03 Family Planning advice: V25.09 IUD insertion: V25.1 OCP surveillance; V25.41 IUD surveillance: V25.42 Implantable subdermal contraceptive: V25.43 Other FPM surveillance; V25.49
ICD-9 Examples (Continued) Abnormal Pap (795) AGUS : 795.00 ASCUS: 795.01 ASCUS cannot rule out HGSIL: 795.02 LGSIL: 795.03 HGSIL: 795.04 HPV High Risk DNA Test Positive: 795.05 Pap with cytological evidence of malignancy: 795.06 Satisfactory cervical smear lacking transformation zone: 795.07 Unsatisfactory cervical cytology Smear: 795.08 Abnormal Glandular Pap of Vagina: 795.10 Abnormal Pap Smear, Anus & Anal HPV: 796.79
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Outpat. Consult New Pat. 99241 99201 Problem Focused 99242 99202 Exp. Problem Focused E&M: Outpatient New Patients and Consults NEW PATIENTS & CONSULTS (3 of 3 Required: GO TO THE LOWEST) History Exam MDM Time New / Cons Prob. Focused (<1 BA/OS) Exp. Prob. Focused (2-4 BA/OS) 99243 99203 Detailed Detailed (5-7 BA/OS) 99244 99204 Comprehensive Comprehensive (8+ OS) 99245 99205 Comprehensive Comprehensive (8+ OS) Straightforward 10/15 Straightforward 20/30 Low Complexity Moderate Complexity High Complexity NOTE: New Patient Definition: Has not had face to face service by a provider of the same specialty within a group practice in 3 years. 30/40 45/60 60/80 *** 2 nd Opinion Consults deleted 2006 to indicate a consult is mandated by a third party payer use Modifier 32
E&M: Outpatient Established Patients ESTABLISHED PATIENTS (2 of 3 Required: GO TO THE MEDIAN - MIDDLE) CPT History Exam MDM Time 99211 PROVIDER NOT REQUIRED 5 99212 Problem Focused 99213 Exp. Problem Focused Prob. Focused (<1 BA/OS) Exp. Problem Focused (2-4 BA/OS) 99214 Detailed Detailed (5-7 BA/OS) 99215 Comprehensive Comprehensive (8+ OS) Straightforward 10 Low Complexity 15 Moderate Complexity High Complexity 25 40
E&M Services The Time Component Only used when counseling or coordination of care represents greater than 50% of time spent with the patient Clock time, i.e., 9:01am - 9:58am Spent 20/25 minutes counseling Re:.. Outpatient is face to face: clinician only Inpatient is floor or unit time Does not have to be continuous Phone time does not count > 50%, C 3
Coding Examples E&M Service for Contraception New or established BCM check HOPE EC NOT retail sales (window only) Procedure and Office Visit Same DOS (CPT) New/ Est Patient E&M (-25) and Surgical Code 99202-25 and 58300 (IUD insert) 99213-25 and 11975 & J7307 (Implanon insert & Rx) Preventive Visit & Problem visit at the same encounter (IOM MCPM Chpt. 12 Section 30.6.2) Contraception does NOT warrant separate problem E&M at time of preventive service *25 Modifier: Significantly, separately identifiable E&M on same day as another E&M service or surgery
Coding Examples OCP Distribution Pill sale only (no encounter), pills only (J8499?); No E&M Exam room encounter with pills code E&M and J8499 Emergency Contraception see OCP Distribution (V25.03) Anticipatory Guidance & Risk Factor Reduction Codes: 99401-99404 Some payers for OCP & general counseling Package Pricing Include all line items with maximum charge Prompt pay option vs.. scheduled payments CLEARLY defined list of included/excluded services (especially for surgical packages)
Coding Examples Injection Coding Surgical service only Analogous to 95115, allergy shot Unless 25 modifier opportunity Depo-Provera Injection: 96372 (Therapeutic/diagnostic injection) & J1055 (Depo) 99211 Payer Specific Sole reason for visit = injection 96372 or 99211 only OV for infection or FP / annual Code E&M & 96372 & J1055 (96372 may be bundled into payment for E&M)
Coding Examples Implantable Contraceptive Capsules 11975: Insertion of Implanon 11976: Removal of Norplant, Implanon 11977: Insertion and Removal J7307: Implanon (supply code) NOT: 11981-11983 for non-biodegradable implant IUD 58300: IUD insertion 58301: IUD removal J7300: Intrauterine copper (supply code) J7302: Mirena (supply code) Global Package Concept 0 Days for Contraceptive Procedures
Summary Easy to Use Encounter Form (Clinician and Billing Involvement) Coding Accuracy with Supporting Documentation Streamlined Data Flow Front Line Feedback (From Payment Posting) Commit to Educate (Top down) Update Constantly
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